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CLINICAL HEMATOLOGY 



DaCOSTA 



CLINICAL 

HEMATOLOGY 



A PRACTICAL GUIDE 

TO THE 

EXAMINATION OF THE BLOOD WITH 
REFERENCE TO DIAGNOSIS. 



By 

JOHN C. DaCOSTA, Jr., M.D. 

ASSISTANT DEMONSTRATOR OF CLINICAL MEDICINE, JEFFERSON MEDICAL COLLEGE 
HEMATOLOGIST TO THE GERMAN HOSPITAL, ETC. 



Containing Eight Full-Page Colored Plates, Three Charts 
and Forty-Eight other Illustrations. 




PHILADELPHIA : 
P. BLAKISTON'S SON & CO. 

IOT2 WALNUT STREET 

i 9 o i 




THE L58RAHV Ol- 

CONGRESS, 
Two Conies Receiveb 

DEC. 2? 1901 

OOPVSIGHT ENTRY 

CLASS (\s 

1- I 0 



Copyright, 1901, 
P. Blakiston's Son & Co. 



KXc wo. 
8. 



TO 

MY FATHER, 
JOHN C. DaCOSTA, M.D., 

THESE PAGES ARE 

AFFECTIONATELY DEDICATED. 



PREFACE. 



This book, designed as a practical guide to the examination of 
the blood by methods adapted to routine clinical work, repre- 
sents an endeavor to recount the salient facts of hematology as 
they are understood at the present time, to correlate certain of 
these facts with familiar pictures of disease, and to apply them to 
medical and surgical diagnosis. The purpose has been to inter- 
pret the blood report according to its true value as a clinical sign, 
neither exploiting it as a panacea for every diagnostic ill, nor 
belittling it because of its failure consistently to give the sought- 
for clue in every instance. 

A minimum amount of theoretical discussion has been intro- 
duced in the sections dealing with the physiology and pathology 
of the whole blood and of the cellular elements — only sufficient, 
in the author's judgment, to add clearness to a number of the 
mooted points of this science, which in its present transitional 
stage must still be regarded as one from which more or less hy- 
pothesis and conjecture are inseparable. Intimate familiarity with 
technique being an essential qualification for the comprehensive 
study of the blood, a somewhat lengthy consideration of this sub- 
ject is given. The methods of examination likely to prove useful 
in every-day practice have been described in detail, perhaps some- 
times at the risk of prolixity, in the hope of thus simplifying for 
the novice the minutiae of blood counting, staining, and other 
means of investigation. In the discussion of the primary anemias 
and of the anemias peculiar to infancy, prominent clinical features 
other than those referable to the blood have been briefly men- 
tioned, in order to add clearness to the differential diagnosis. For 
convenience in reference, the various diseases included in the sec- 
tion on general hematology are arranged alphabetically, rather 
than grouped according to a traditional classification. 

The greater part of the original data referred to in the text is 
taken from the records of the Pathological Institute of the Ger- 
man Hospital, where a systematic account of all blood examina- 
tions has been kept for the past six years. The remaining data 
represent the writer's personal examinations in hospital and pri- 
vate practice and in the army medical service, these sources of 
statistics together including about four thousand blood reports in 
various pathological conditions. 

vii 



viii 



PREFACE. 



Hematological literature has been freely consulted in the prep- 
aration of this volume, special acknowledgment being due to 
Hayem, Ehrlich and Lazarus, von Limbeck, Rieder, Lowit, 
Turk, Grawitz, Cabot, Stengel, Thayer, Ewing, Taylor, and Coles 
for the profitable information gleaned from their writings. Due 
credit in the text has been given to these as well as to the other 
authors of whose labors use has been made. 

The colored plates and other histological illustrations, the 
originals of which were made by Mr. E. F. Faber from fresh and 
stained specimens, bear evidence of the artist's technical skill and 
faithful attention to structural detail. Mr. S. Trenner has kindly 
furnished the engravings of several of the special instruments. 

The author takes pleasure in acknowledging the assistance of 
his wife and critic in revising the proof of these pages ; in credit- 
ing Dr. G. P. Muller for collecting and verifying much statistical 
matter relating to hospital cases ; and in thanking Dr. J. Chal- 
mers Da Costa and Dr. T. G. Ashton for helpful suggestions. 

313 South Thirteenth Street, Philadelphia, 
November, 1901. 



INTRODUCTION. 



The rapid growth and development of hematology during re- 
cent years and the practical application of many of its teachings 
to the diagnosis of various diseases have made this science one 
which no progressive medical man can afford to disregard. Ex- 
amination of the blood gives definite clinical information which 
may be profitable both to the practitioner of internal medicine 
and to the surgeon, and the procedure is capable of throwing 
light upon the diagnosis in such a wide range of pathological 
conditions that it is difficult to single out any disease in which it 
may not be of some utility, either as positive or as negative evi- 
dence. 

In the light of our present knowledge of the subject, clinical 
information of two different kinds may be derived from hematol- 
ogy, namely, findings which are pathognomonic of certain dis- 
eases ; and auxiliary data which, if considered in connection with 
other clinical manifestations, may prove either essential or helpful 
in establishing the precise nature of a disease. 

Pathognomonic blood findings are unfortunately confined to a 
limited number of diseases : leukemia, the malarial fevers, relaps- 
ing fever, and filariasis. In pernicious anemia a typical picture 
is also found, if two conditions capable of exciting identical blood 
changes are excepted, the profound secondary anemias due to 
certain intestinal parasites and to nitrobenzol poisoning. 

The blood examination affords data which, although not pa- 
thognomonic, are nevertheless essential for the diagnosis of chlo- 
rosis, Hodgkin's disease, splenic anemia, and secondary ane- 
mias dependent upon various causes. For example, in chlorosis 
a definite group of blood changes must exist in order to justify 
an unconditional diagnosis, although the occurrence of these 
changes, unassociated with other equally definite clinical signs, 
is insufficient evidence of this disease. In Hodgkin's disease, a 
condition indistinguishable from leukemia by an ordinary phys- 
ical examination, the absence of a leukemic state of the blood at 
once excludes the latter disease. In the secondary anemias, it is 
obvious that the blood count alone can give the exact clue to the 
condition, by determining the degree and character of the blood 
impoverishment, and by tracing from time to time its progress. 

ix 



X 



INTRODUCTION. 



In this connection it is important to remember that pallor may 
go hand in hand with a normal hemoglobin percentage and eryth- 
rocyte value, and that on the other hand a high color by no 
means invariably signifies that the individual is not anemic. In 
addition to the diseases just named, hematology gives informa- 
tion which is often of great assistance in, although not essential 
for, the diagnosis of such conditions as enteric fever, sepsis, 
pneumonia, appendicitis, diabetes, syphilis, malignant disease, 
trichiniasis, and suppurative processes. Clinical experience has 
repeatedly illustrated the value of the serum reaction in typhoid 
and in Malta fevers, of Williamson's test in diabetes mellitus, of 
eosinophilia in trichiniasis, and of leucocytosis in sepsis, malignant 
neoplasms, suppurative lesions, and many of the acute infections. 

Negative results from a blood examination also possess diag- 
nostic value within certain limits, but too great reliance upon evi- 
dence of this sort more often proves delusive than helpful. In a 
patient whose waxy, yellowish facies suggests with equal force 
pernicious anemia, chronic nephritis, and, perhaps, liver cirrhosis, 
the absence of characteristic blood changes is sufficient to exclude 
the first-named condition. But failure to detect the malarial para- 
site does not necessarily exclude malarial fever ; a negative serum 
test does not absolutely rule out enteric fever ; and an absence of 
leucocytosis cannot be regarded as an infallible sign that a sup- 
purative focus does not exist, nor does it always indicate the 
benignity of a neoplasm. Negative evidence, then, is usually to 
be considered merely suggestive, the real pertinence of the hint 
thus obtained depending upon its correlation with other physical 
signs and symptoms. 

The significance of positive findings in bacteriological investiga- 
tions of the blood is patent, and the conclusive value of this 
means of research in identifying obscure cases of general sepsis, 
malignant endocarditis, enteric fever, and plague, has been demon- 
strated in many instances. The conflicting and indifferent results 
which some investigators have obtained by this procedure were 
doubtless due largely to faulty technique, but these results promise 
to become more dependable and certain with the adoption or 
more exact technical methods. 

At the present time the most useful information furnished by 
hematology has been derived from study of the cellular elements 
of the blood, but closer familiarity with the chemistry of this 
tissue, still an undeveloped science, will undoubtedly in the near 
future afford not only more tangible clues to the etiology and 
pathology of the blood diseases, but also will bring to light addi- 
tional facts which may be applied to the diagnosis of these and 



INTRODUCTION. 



XI 



other maladies. The study of the coagulation time of the blood 
already promises to be of practical utility in the diagnosis and 
prognosis of cases of purpura, hemophilia, and jaundice, which 
are characterized by slow clotting and by a tendency toward 
hemorrhage. 

The technique of blood examinations, such as described in 
the following pages, is neither elaborate nor difficult to master. 
Necessarily, it must be rigidly exact, but no more so than any 
other branch of physical diagnosis, if the worker is content only 
with the best results. To acquire a good working knowledge of 
hematology takes but a fraction of the time and application that 
one must spend in familiarizing one's self with the most com- 
mon heart murmurs or chest signs, and the time thus spent 
equips the physician with an additional diagnostic agent of the 
greatest value. If the newly-graduated physician would provide 
himself with a microscope and a set of blood instruments, and 
systematically study the blood in the various general diseases 
which he encounters in practice, many a slip-shod diagnosis 
might be avoided, and a great stride forward made in popularizing 
this practical branch of clinical diagnosis. 



TABLE OF CONTENTS. 



INTRODUCTION 



SECTION I. 

EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

Page. 

General Schema . 19 

I. Examination of the Fresh Blood 19 

Obtaining the Specimen 19 

Preparing the Slide . • • • • • . 21 

Microscopical Examination ....... 22 

Changes Affecting the Erythrocytes • ■ • • • 22 

Changes Affecting the Leucocytes 23 

Increase of Fibrin, Blood Plaques, and Hemoconia . . 24 

Blood Parasites ......... 24 

Foreign Bodies . 24 

II. Estimation of the Percentage of Hemoglobin • • 25 

Von Fleischl's Hemometer . . . . . . . 25 

Oliver's Hemoglobinometer . 32 

Gowers' Hemoglobinometer ....... 34 

Dare's Hemoglobinometer . 36 

Tallquist's Method ........ 39 

III. Counting the Erythrocytes and the Leucocytes . 40 
Methods .......... 40 

Diluting Fluids ......... 40 

The Thoma-Zeiss Hemocytometer 42 

Counting the Erythrocytes 45 

Counting the Leucocytes ....... 49 

Cleaning the Pipette ........ 52 

Durham's Hemocytometer . . . . . . 52 

Gowers' Hemocytometer ....... 54 

Oliver's Hemocytometer ...... 56 

IV. Microscopical Examination of the Stained Specimen e 58 
Objects of Staining ........ 58 

The Aniline Dyes ......... 59 

Preparing the Films ........ 59 

Fixation Methods . 61 

Methods of Staining ........ 63 

Ehrlich's Triacid Stain ........ 64 

Jenner's Stain . 65 

Prince's Stain 66 



xiii 



XIV 



TABLE OF CONTENTS. 



Page. 

Staining with Eosin and Methylene-blue .... 67 

Staining with Eosin and Hematoxylin ..... 68 

Staining with Thionin 69 

Staining with Polychrome Methylene-blue .... 69 

Differential Counting ........ 70 

V. Counting the Blood Plaques 71 

Determann's Method ........ 72 

VI. Estimation of the Relative Volumes of Corpuscles and 

Plasma . . 72 

Daland's Hematocrit 73 

Limitations of the Hematocrit ...... 74 

VII. Estimation of the Specific Gravity .... 75 
Hammerschlag's Method 75 

VIII. Estimation of the Alkalinity ... . . . 77 

Engel's Alkalimeter 77 

IX. Determination of the Rapidity of Coagulation . 79 

Glass Slide Method 80 

Wright's Coagulometer . . . . . . . 80 

X. Spectroscopics Examination . . . . . 81 

The Sorby-Beck Microspectroscope 81 

XI. Bacteriological Examination 83 

Value of Positive Findings ....... 83 

Methods . 83 

Blood Cultures . 83 

Staining Methods ........ 85 

XII. Determination of the Serum Reaction ... 86 

Widal's Test . 86 

The Specific Test for Human Blood ..... 88 

SECTION II. 
THE BLOOD AS A WHOLE. 

I. General Composition 93 

Plasma, Serum, and Cells ....... 93 

Salts ........... 93 

Extractives .......... 94 

Gases ........... 94 

II. Color 94 

Normal Variations ........ 94 

Density and Opacity ........ 94 

Pathological Variations . . . . . . . 94 

III. Odor and Viscosity ........ 95 

IV. Reaction 95 

Reaction in Health . . 95 



TABLE OF CONTENTS. XV 

Page. 

Table of Normal Blood Alkalinity 96 

Physiological Variations ....... 96 

Pathological Variations 97 

V. Specific Gravity 98 

Normal Range . 98 

Pathological Variations 99 

Relation of Specific Gravity to Hemoglobin .... 99 

Table of Hemoglobin Equivalents 100 

VI. Fibrin and Coagulation 100 

Relation of Fibrin to Coagulation . . • • . 100 

Appearance of Fibrin in Fresh Blood • . • • . 101 

Hyperinosis and Hypinosis ....... 102 

Pathological Variations in Amount of Fibrin . . . • 102 

VII. Oligemia 103 

Definition .......... 103 

Occurrence . . . • . • • . 103 

VIII. Plethora .......... 104 

Definition . . . . . . . . 104 

Permanent and Transient Polyemia • • • - • 104 

Serous Plethora . . . . . . . . . 104 

Cellular Plethora . 105 

IX. Hydremia .105 

Definition . . . . . . 105 

Causes 105 

Occurrence . . 105 

X. Anhydremia 106 

Definition .......... 106 

Causes . . . . . . . . . . . 106 

Occurrence . . . . . . . . . 106 

XI. Lipemia . . . 106 

Amount of Fat in Normal Blood 106 

Definition . . . . . . . . . 107 

Physiological and Pathological Lipemia 107 

Tests for Fat . 107 

XII. Melanemia . . 107 

Definition . . . . . . . . . . 107 

Occurrence . . . . . . ... . 108 

XIII. Glycemia . . . 108 

Amount of Sugar in Normal Blood 108 

Hyperglycemia . . 108 

Test for Sugar . " 108 

XIV. Uricacidemia . . . 109 

Definition . . . . . . . . • / • io 9 

Occurrence • . . . . . . 109 

Test for Uric Acid . 109 



xvi 



TABLE OF CONTENTS. 



Page. 



XV. Cholemia no 

Definition . . no 

Occurrence . . • • . • . . no 

Test for Bile . . . • • . . . . no 

XVI. Acetonemia and Lipacidemia . . • . . no 

Definition .no 

Occurrence . . • • • • . . no 

Tests for Acetone and Fatty Acids ■ . . . . no 

XVII. Bacteriemia . . .in 

Occurrence . . . • • • • • . 1 1 1 

Latent Infection . 1 1 1 

Blood Cultures . . . 112 

Bacteria Found in the Blood 112 

XVIII. Anemia .113 

Definition . . . . . . . . . . . 113 

Pseudo-anemia . . . . . . . . . 113 

Classification . . . . . . . . 114 

Pathogenesis . . . • . . . • . 115 

SECTION III. 

HEMOGLOBIN, ERYTHROCYTES, BLOOD PLAQUES, 
AND HEMOCONIA. 

I. Hemoglobin . . • ■ • • . . 119 

General Properties • • • • • • . 119 

Origin . . • . • • ... 120 

Variations in Amount . • • • • . • . 121 

Absolute Amount . 122 

Color Index . . • . • . . • .122 

Hemoglobinemia . . . ... . . . 123 

Methemoglobinemia . . . . . . . . 124 

Carbon Monoxide Hemoglobin . . . • • . 125 

II. Erythrocytes . 126 

Appearance in Fresh Blood • . . . . . . 126 

Histological Structure . . . . . . • . 127 

Origin and Life History 128 

Size . . . . . . • . . . 129 

Normal Number . 129 

Volume Index . . . . . . . . . 130 

III. Influence of Physiological Factors on the Eryth- 

rocytes . 130 

Age and Sex . . . . . . . . . 130 

Pregnancy, Menstruation, and Lactation . . . 131 

Constitution and Nutrition 132 

Fatigue . . ........ 132 

Digestion and Food . . . . . . . . 132 

High Altitudes . . . . . . . . 133 



TABLE OF CONTENTS. Xvii 

Page. 

IV. Pathological Changes in the Erythrocytes . • 134 

Ameboid Motility 134 

Alterations in Isotonicity 135 

Hyperviscosity . . . • • • • • . 136 

Deformities of Shape and Size • • ' • • . 136 

Megalocytes . . . . • • . 136 

Microcytes . . . . . • • . 137 

Poikilocytes . • • • . • • 137 

Endoglobular Degeneration . . . . . 138 

Total Necrosis . . ....... 139 

Atypical Staining Reaction . . . . • . . 140 

Nucleation . . . . . . . - . . . . 141 

Normoblasts 141 

Megaloblasts 143 

Microblasts . . . . . . . . • 145 

Atypical Erythroblasts . . . • • . . 146 

Granular Degeneration . . . . . . . 147 

Oligocythemia . .148 

Polycythemia . . . . . . . . . 149 

V. Blood Plaques . . 1 50 

Appearance in Fresh Blood . • • • • . . 150 

Histological Structure . . . . . . . . 150 

Origin . . . . • . . . . . 150 

Normal Number . 151 

Pathological Variations . . . . . . 151 

VI. Hemoconia 151 

Appearance in Fresh Blood . . . . . . . 151 

Histological Characteristics • • • • • • • 151 

Occurrence . . . . . . . . . 151 



SECTION IV. 

THE LEUCOCYTES. 

I. General Characteristics 155 

Appearance in Fresh Blood 155 

Ameboid Movement 156 

Cell Granules . . . . • . . . . 157 

Normal Number . . . . . . . . . 159 

II. Classification . . . . . . . . . 159 

Number and Percentage of Different Varieties • . . 159 

Small Lymphocytes . . . . . . . . 160 

Large Lymphocytes 161 

Transitional Forms . . . . . . . . 162 

Polynuclear Neutrophils 163 

Eosinophiles . . . . . . . . . 165 

Basophile Cells 166 

Myelocytes . . 167 

Mast Cells .168 

1* 



xviii 



TABLE OF CONTENTS. 



Page. 



Mononuclear Neutrophiles . . . • • • . 171 

Neutrophilic Pseudolymphocytes 171 

Reizungsformen . . . . . • • • . 171 

Differential Table of the Leucocytes . . . . . 172 

Origin and Development 173 

Iodine Reaction . . . • • • • ■ . 174 

Perinuclear Basophilia . . • . • • • • • l 7& 

III. Leucocytosis .176 

Definition . . . . • • • • . 176 

Classification of the Leucocytoses • • . • . . 177 

Physiological Leucocytosis 177 

Character . . . • . . . . 177 

Causal Factors . . . . . . . . 178 

Leucocytosis of the New-born . . • • . 178 

Digestion Leucocytosis . . . . . . . 179 

Leucocytosis of Pregnancy and Parturition . . . 180 

Leucocytosis Due to Thermal and Mechanical Influences 18 1 

Terminal Leucocytosis 181 

Pathological Leucocytosis . . . . . . . 182 

Occurrence . . . • . • . . .182 

Degree of Increase 183 

Differential Changes . . . . • . . 183 

Causal Factors . 184 

Functions . .184 

Hypoleucocytosis and Hyperleucocytosis . . . 185 

Inflammatory and Infectious Leucocytosis . . . 187 

Leucocytosis of Malignant Disease . . . . 190 

Post-hemorrhagic Leucocytosis . . . . . 191 

Toxic Leucocytosis . . . . . . . 192 

Experimental Leucocytosis . . . . . . 193 

IV. Lymphocytosis 196 

Definition . . . . . . . . . . 196 

Differential Changes . . . . ... . 196 

Causal Factors . 197 

Physiological Lymphocytosis • . . . . . 197 

Pathological Lymphocytosis . . . . . . . 197 

Experimental Lymphocytosis • . . . . . 198 

Clinical Significance . . . . . . .. 198 

V. EOSINOPHILIA 198 

Definition . . . . . . . , . . 198 

Causal Factors . . . . . . . . 199 

Physiological Eosinophilia 199 

Pathological Eosinophilia . . . . . . . 200 

Experimental Eosinophilia . . . . . . . 201 

Diminution in the Number of Eosinophiles .... 201 

Clinical Significance 201 



VI. Basophilia 



202 



TABLE OF CONTENTS. XIX 

Page. 

VII. MYELEMIA . * 202 

Definition 202 

Occurrence 202 

Causal Factors ......... 203 

VIII. Leucopenia 203 

Definition . . . • • . . . . . 203 

Differential Changes . • 204 

Physiological Leucopenia 204 

Pathological Leucopenia 205 

Experimental Leucopenia 207 

SECTION V. 
DISEASES OF THE BLOOD. 

I. Chlorosis 209 

Appearance of the Fresh Blood 209 

Coagulation .......... 209 

Specifie Gravity 209 

Alkalinity . . 219 

Hemoglobin and Erythrocytes 210 

Color Index .......... 210 

Deformed and Nucleated Cells 210 

Leucocytes . . . . • . . . . .213 

Differential Changes . . • . . . . . 214 

Blood Plaques . 215 

Diagnosis . . . . . - 216 

Clinical Features . 216 

II. Pernicious Anemia 218 

Appearance of the Fresh Blood . . . . . 218 

Coagulation . . . . . . . . . . 219 

Specific Gravity . . . . . . . . 219 

Alkalinity 220 

Hemoglobin and Erythrocytes 220 

Color Index . . . 220 

The Blood During Remissions . . . . . . 221 

Megalocytosis . . . . . . . . . 221 

Poikilocytosis . . . . . . . . . 223 

Prevalence of Megaloblasts ....... 224 

Polychromatophila . . . . . . . . 225 

Granular Basophilia ........ 226 

Leucocytes . . . ■ . . . . . . 227 

Differential Changes . . . . . . . . 227 

Blood Plaques . . . . . . . . . 228 

Diagnosis ; . . . . . . ... 228 

Clinical Features . . . . . . . . . 229 

Pernicious Anemia and Severe Secondary Anemia • . 230 

Pernicious Anemia and Chlorosis 230 

Pernicious Anemia and Bothriocephalus Anemia • • . 231 

Pernicious Anemia and Nitrobenzol Poisoning . . . 231 



XX 



TABLE OF CONTENTS. 



Page. 



III. Splenic Anemia 231 

Appearance of the Fresh Blood 231 

Hemoglobin and Erythrocytes . . . . • . 231 

Color Index . ......... 231 

Deformed and Nucleated Cells ...... 232 

Leucocytes 233 

Blood Plaques . 233 

Diagnosis 233 

Clinical Features . . . . . . . . . . 234 

Splenic Anemia and Spleno-medullary Leukemia . . . 235 

Splenic Anemia and Pernicious Anemia .... 235 

Splenic Anemia and Hodgkin's Disease .... 235 

Splenic Anemia and Splenic Tumors ..... 235 

IV. Secondary Anemia 236 

Appearance of the Fresh Blood 236 

Coagulation .......... 236 

Specific Gravity . . . • . . . . . 236 

Alkalinity .......... 237 

Hemoglobin and Erythrocytes . ... . . . 237 

Color Index .......... 237 

Deformed and Nucleated Cells . . . . . . 238 

Leucocytes . . . . . . . . . . 238 

Differential Changes ........ 238 

Blood Plaques . 239 

Diagnosis . . . . . . . ... . 239 

V. Post-hemorrhagic Anemia 239 

Etiology 239 

Immediate Effects of Hemorrhage ... . 240 

Secondary Effects of Hemorrhage ...... 240 

Degree of Blood Loss Compatible with Life .... 240 

Regeneration of the Blood 241 

Differential Table . . 243 

VI. Leukemia 244 

Varieties .......... 244 

Parasitology .......... 244 

Spleno-medullary Leukemia 246 

Appearance of the Fresh Blood ..... 246 

Coagulation . . . . . . . 247 

Alkalinity ......... 247 

Specific Gravity 247 

Hemoglobin and Erythrocytes • • • • 247 

Color Index . 248 

Relation of Erythrocyte and Leucocyte Counts . . 248 

Nucleated Cells 248 

Leucocytes ......... 250 

Influence of Arsenic on the Leucocyte Count . . . 250 

The Blood During Remissions . . . . . 251 

Differential Changes . . . . . . 252 

Blood Plaques . 256 



TABLE OF CONTENTS. XXI 

Page. 

Lymphatic Leukemia 256 

Appearance of the Fresh Blood 256 

Hemoglobin and Erythrocytes 257 

Color Index • 257 

Deformed and Nucleated Cells 257 

Leucocytes . . . • • • • • • 258 

Differential Changes 259 

Blood Plaques . . . • • • 260 

Acute Leukemia ......... 260 

Influence of Intercurrent Infections 261 

Diagnosis . 263 

Spleno-medullary and Lymphatic Leukemia . 264 

Leukemia and Pathological Leucocytosis .... 265 

Leukemia and Lymphocytosis 265 

Leukemia and Hodgkin's Disease 266 

Leukemia and Tumors of the Spleen, Kidney, and Pancreas 266 

Leukemia and Lymphatic Hyperplasia 266 

VII. Hodgkin's Disease 267 

Appearance of the Fresh Blood ...... 267 

Alkalinity, Specific Gravity, and Coagulation . • . 267 

Hemoglobin and Erythrocytes 267 

Color Index 267 

Nucleated and Deformed Cells 267 

Leucocytes 268 

Differential Changes 268 

Diagnosis .......... 269 

Clinical Features . . . . . . . . . 270 

Hodgkin's Disease and Tuberculous Adenitis . . . 271 

Hodgkin's Disease and Syphilitic Adenitis . . • . 271 

Hodgkin's Disease and Local Lymphoma • • • • 271 

Hodgkin's Disease and Lymphatic Sarcoma . . • . . . 271 

Hodgkin's Disease and Lymphatic Carcinoma • • • 272 

VIII. The Effect on the Blood of Splenectomy • • 272 

Hemoglobin and Erythrocytes 272 

Leucocytes . 272 

Differential Changes . . .. . . . . . 274 

Factors of the Blood Changes Following Splenectomy • • 274 

Differential Table . . 275 

SECTION VI. 
THE ANEMIAS OF INFANCY AND CHILDHOOD. 

I. Characteristics of the Blood in Children • • • 279 

Fetal Blood 279 

The Blood at Birth . . 280 

II. Anemia in Children 282 

Frequency . . . . . . . . . 282 

General Characteristics . 283 



Xxii TABLE OF CONTENTS. 

Page. 

Classification 283 

Primary Anemia . 284 

Pernicious Anemia 284 

Leukemia . 284 

Secondary Anemia 287 

Mild Anemia . 287 

Severe Anemia ......... 287 

Anemias with Leucocytosis • .. . . . 287 

Etiology of Secondary Anemia 288 

Anemia Due to Syphilis 288 

Anemia Due to Rachitis 288 

Anemia Due to Tuberculosis ...... 289 

Anemia Due to Gastro-intestinal Diseases . . . 289 

Post-typhoid Anemia 289 

Anemia Infantum Pseudoleukemica .... 290 

Bacteriemia in Children 292 

SECTION VII. 
GENERAL HEMATOLOGY. 

I. Abscess 295 

Coagulation, Fibrin, and Iodine Reaction . . . . 295 

Hemoglobin and Erythrocytes ...... 295 

Factors of the Anemia in Abscess ..... 295 

Color Index . . ....... 295 

Grade of Anemia in Different Forms of Abscess • • 296 

Cell Deformity and Nucleation 296 

Leucocytes ......... 296 

Relation of the Leucocyte Count to the Local Lesion • • 297 

Range of the Leucocyte Count in Different Forms of Abscess 297 

Differential Changes 297 

Diagnosis .......... 297 

II. Acromegaly . . . . . . . . 298 

III. Actinomycosis . 298 

IV. Acute Yellow Atrophy of the Liver . 298 

V. Addison's Disease . . 299 

VI. Anthrax . . . . . . . • . 299 

VII. Appendicitis 300 

Factors of the Anemia in Appendicitis .... 300 

Grade of Anemia in Catarrhal and Suppurative Cases • • 300 

Hemoglobin and Erythrocytes 300 

Cell Deformity and Nucleation • • • • • • 301 

Leucocytes .301 

Range of the Leucocyte Count in Different Forms of Appendi- 
citis 302 

Differential Changes 302 

Diagnosis .......... 302 



TABLE OF CONTENTS. Xxiii 

Page. 

VIII. Asiatic Cholera 304 

IX. Asthma and Emphysema 305 

X. Bronchitis . . • • • • , • • . 306 

XL Bubonic Plague 306 

Bacteriology ......... 306 

Serum Reaction . . . . - . • . . 307 

Hemoglobin and Erythrocytes ...... 307 

Leucocytes . 307 

Blood Plaques 308 

XII. Cholelithiasis . . . . < . • . 308 

Fibrin and Coagulation 308 

Bacteriology . 308 

Hemoglobin and Erythrocytes 308 

Leucocytes . . . . . • • . 309 

Diagnosis .......... 309 

XIII. Diabetes Mellitus 309 

Alkalinity, Lipemia, Lipacidemia, and Glycemia . . . 309 

Williamson's Test . . . . . . . 309 

Bremer's Test . . . . . . . . . 310 

Hemoglobin and Erythrocytes 311 

Leucocytes . . 312 

Digestion Leucocytosis . . . . . . . . 312 

Iodine Reaction . . . . . . . . .. 312 

Diagnosis . . . . . . . . . . 312 

XIV. Diphtheria . 312 

Hemoglobin and Erythrocytes . . . . . 312 

Leucocytes . . . . . . . . . . 313 

Course of the Leucocytosis . . . . • . 314 

Influence of Antitoxin on the Leucocyte Count . . . 314 

Differential Changes 315 

Affinity of the Leucocytes for Basic Dyes . . . . 315 

Diagnosis . . . . . . . . . . 316 

XV. Enteritis . . . . . . . . . 316 

Acute Catarrhal, Chronic Ulcerative, and Phlegmonous . 316 

Gastro- enteritis . . . . . . . . . 316 

Dysentery . . . . . . . . . . 316 

Effect of Saline Purges 316 

XVI. Enteric Fever 317 

Bacteriology . . . . . . . . . 317 

Blood Cultures . 317 

Spot Cultures . . . . ... . . 318 

Serum Reaction . . . . . . . . . 319 

Hemoglobin and Erythrocytes 326 

Cell Deformity and Nucleation 328 

Leucocytes . . . . 328 

Differential Changes ........ 330 

Effect of Complications ....... 330 



xxiv 



TABLE OF CONTENTS. 



Page. 



Blood Plaques . . 331 

Diagnosis . . . . • . . . . . 331 

XVII. Erysipelas 332 

XVIII. Exophthalmic Goitre 333 

XIX. Fever . . • . 333 

Factors of the Blood Changes 333 

Pyrexial Polycythemia 333 

Post-febrile Anemia 334 

Coagulation, Fibrin, and Leucocytes ..... 334 

Alkalinity 334 

XX. Filariasis 334 

Occurrence 334 

Parasitology .......... 335 

The Filaria Nocturna . . . . . . . . 335 

Technique of Examination ....... 340 

Staining the Filarial 341 

Hemoglobin and Erythrocytes ■ . • • . . 341 

Leucocytes 342 

Diagnosis . . t m • . . . . . 342 

XXI. Fractures . . 343 

XXII. Gastritis 343 

Acute and Chronic Forms 343 

Hyperchlorhydria, Hypochlorhydria, Gastric Achylia, Gastric 

Dilatation, Gastric Neurasthenia ..... 344 

Diagnosis 344 

XXIII. Gastric Ulcer 345 

Hemoglobin and Erythrocytes 345 

Effects of Hemorrhage and Emesis . . . . 345 

Leucocytes .......... 345 

Diagnosis . . . . . . . . . . 345 

XXIV. Glanders 346 

XXV. Gonorrhea 346 

XXVI. Gout 347 

Alkalinity and Fibrin . ....... 347 

Uric Acid . . . . • , . . . 347 

Cellular Elements 347 

Perinuclear Basophilia 348 

XXVII. Hemorrhagic Diseases 348 

Specific Gravity ......... 348 

Bacteriology ......... 348 

Alkalinity .......... 348 

Coagulation . 349 

Hemoglobin and Erythrocytes ...... 349 

Leucocytes . . . . . . . . . 350 

Blood Plaques ......... 350 



TABLE OF CONTENTS. 



XXV 



XXVIII. Hepatic Cirrhosis 

Anemia in Atrophic Cirrhosis .... 

Effect of Ascites ........ 

Anemia in Hypertrophic Cirrhosis . < • 

Leucocytes in Atrophic and Hypertrophic Cirrhoses 
Diagnosis 



XXIX. Herpes Zoster 



XXX. Icterus 

Fibrin, Coagulation, Specific Gravity, and Alkalinity 
Hemoglobin and Erythrocytes .... 
Leucocytes . 

Diagnosis ... ..... 



XXXI. Influenza 

XXXII. Insolation 



XXXIII. Intestinal Helminthiasis 
Factors of the Blood Changes 
Hemoglobin and Erythrocytes 
Bothriocephalus Anemia 
The Anemia of Ankylostomiasis - 
Leucocytes .... 



Groups 



XXXIV. Intestinal Obstruction .... 

XXXV. Leprosy 

XXXVI. Malarial Fever 

Parasitology . . ..... 

Developmental Cycle of the Malarial Parasite in Man 
Developmental Cycle of the Malarial Parasite in the Mo 
Varieties of the Malarial Parasite 
The Parasite of Tertian Fever 

Infections with Single and Multiple 

Anticipation of the Paroxysm 

Intracellular Hyaline Forms . 

Intracellular Pigmented Forms 

Segmenting Forms 

Extracellular Pigmented Forms 

Flagellate Forms . 

Degenerate Forms . 
The Parasite of Quartan Fever 

Infections with Single and Multiple 

Intracellular Hyaline Forms • 

Intracellular Pigmented Forms 

Segmenting Forms 

Extracellular Pigmented Forms 

Flagellate Forms . 

Degenerate Forms 
The Parasite of Estivo-autumnal Fever 

Irregularities in Time of Developmental Cycle 

Disc- and Ring-shaped Forms 



Groups 



quito 



xxvi 



TABLE OF CONTENTS. 



Page. 



Pigmented Forms . . • . . . 372 

Segmenting Forms ....... 372 

Erythropyknosis ........ 372 

Spherical, Ovoid, and Crescentic Forms • • • 373 

Flagellate Forms ........ 374 

Degenerate Forms ....... 374 

Pigmented Leucocytes and Phagocytosis .... 375 

Differential Table of the Malarial Parasites . . ' . . 376 

Technique of Examination ....... 376 

Hemoglobin and Erythrocytes ...... 379 

Causes of Malarial Anemias 379 

Anemia in the Regularly Intermittent Fevers • • • 379 

Anemia in Estivo-autumnal Fever ..... 380 

Anemia in Malarial Cachexia . . . . . . 381 

Types of Post-malarial Anemia . . . . . . 381 

Leucocytes .......... 382 

Differential Changes ........ 383 

Blood Plaques . . . 384 

Diagnosis . . . . . . . . . . 384 

XXXVII. Malignant Disease 384 

Carcinoma . . . . • . ■ • . . 384 

Fibrin and Coagulation • • • • * • • 384 

Specific Gravity and Alkalinity • ... 385 

Glycemia . . . . . . . . 385 

Parasitology ......... 385 

Hemoglobin and Erythrocytes • • • • 385 

Color Index ......... 386 

Regeneration of the Blood after Operation • • • 386 

The Oligocythemia and Polycythemia of Gastric Cancer 386 

Deformed and Nucleated Cells 387 

Leucocytes . . . . . . . . 387 

Frequency of Cancer Leucocytosis ..... 387 

Causes of Cancer Leucocytosis . • . 388 

Range of the Leucocytes in Different Forms of Cancer . 388 

Digestion Leucocytosis in Gastric Cancer . • . 388 

Differential Changes ....... 389 

Sarcoma . . 389 

General Features of the Blood ..... 389 

Hemoglobin and Erythrocytes ..... 389 

Leucocytes . 390 

Diagnosis . . . . . . . . . 391 

XXXVIII. Malignant Endocarditis ... . 392 

Bacteriology . . . . . . . . . . 392 

Hemoglobin and Erythrocytes ... . 393 

Leucocytes 393 

Diagnosis .......... 394 

XXXIX. Malta Fever . 394 

XL. Measles 395 

XLI. Meningitis 396 



TABLE OF CONTENTS. XXvii 

Page. 

XLII. Myxedema 398 

XLIII. Nephritis . . • . • • • . 399 

Factors of the Blood Changes 399 

Specific Gravity, Fibrin, Coagulation, and Alkalinity . . 399 

Bacteriology .......... 399 

Hemoglobin and Erythrocytes ...... 400 

Anemia in Acute and Chronic Parenchymatous Nephritis 400 

Polycythemia . 400 

Anemia in Chronic Interstitial Nephritis . . • . 401 

Leucocytes . . . . . . . • • . 401 

Uremia .......... 401 

Diagnosis .......... 401 

XLIV. Nervous and Mental Diseases . . . . . 402 

Neuritis, Beri-beri, Neuralgia, and Brain Tumor • • • 402 

Neurasthenia, Hypochondriasis, and Hysteria • • . 402 

General Paresis, Dementia, Melancholia, and Mania . . 403 

Convulsions, Apoplectiform Attacks, and Acute Delirium . 404 

Epilepsy, Chorea, and Tetany ...... 405 

XLV. Obesity . . . 405 

XLVI. Osteomalacia 406 

XLVII. Pericardial Effusion . . . • . . 406 

XLVIII. Peritonitis . 407 

XLIX. Pertussis •• • • . 408 

L. Pleurisy . . 409 

Serous Pleurisy ......... 409 

Purulent Pleurisy . . . . ' . . . . 410 

Diagnosis . . . . . . . . . • . 411 

LI. Pneumonia . . 411 

General Features of the Blood . . . . . . 411 

Bacteriology. . . . . . . . • . 411 

Hemoglobin and Erythrocytes . . . . . . 412 

Leucocytes .......... 413 

Relation of Leucocytosis to Intensity of Infection . . . 413 

Frequency and Extent of Leucocytosis . . . • . 413 

Effects of Antipyresis 414 

Differential Changes 415 

Blood Plaques . . 415 

Diagnosis . . 415 

LH. Poisoning . . 416 

LIH. Rabies . . . . . . . . . 417 

LIV. Relapsing Fever •-. . . 418 

Parasitology . . . . . . . . . . 418 

Lowenthal's Reaction 420 

Hemoglobin and Erythrocytes . . . . • . 421 

Leucocytes ... ....... 421 

Diagnosis . . . . . . . . . . . 421 



xxviii 



TABLE OF CONTENTS. 



Page. 

LV. Rheumatic Fever . ....... 421 

Coagulation, Fibrin, and Alkalinity . . . . . 421 

Bacteriology . . . . . 422 

Hemoglobin and Erythrocytes ...... 422 

Leucocytes .......... 423 

Diagnosis .......... 423 

LVI. Scarlet Fever 423 

Coagulation, Fibrin, and Specific Gravity .... 423 

Bacteriology . . . . . . . . . . 424 

Hemoglobin and Erythrocytes 424 

Leucocytes 425 

Blood Plaques ......... 426 

Diagnosis .......... 426 

LVII. Septicemia and Pyemia 427 

Factors of the Blood Changes 427 

Fibrin ........... 427 

Serum Reaction . 427 

Bacteriology 428 

Hemoglobin and Erythrocytes 429 

Color Index 430 

Deformed and Nucleated Cells ...... 430 

Leucocytes . . . . . . . . . 431 

Differential Changes . . 431 

Diagnosis . . . ....... 431 

LVIII. Syphilis 432 

Hemoglobin and Erythrocytes 432 

Syphilitic Chlorosis and Pernicious Anemia .... 432 

Effect of Mercury on the Blood 432 

Justus' Test .433 

Leucocytes . . 434 

Diagnosis . . . . . . . . . 434 

LIX. Tetanus 434 

LX. Tonsillitis 434 

LXI. Trichiniasis . . . . . . • • . 435 

LXII. Tuberculosis . . . . . . • . 437 

General Features of the Blood 437 

Bacteriology .......... 437 

Serum Reaction . 437 

Hemoglobin and Erythrocytes ...... 439 

Anemia in Pulmonary Tuberculosis • . . . 439 

Anemia in Bone Tuberculosis 440 

Anemia in Tuberculous Adenitis, Meningitis, Pericarditis, Pleu- 
risy, and Peritonitis, and in Genito -Urinary Tuberculosis • 440 
Leucocytes ... ....... 441 

Differential Changes . ....... 441 

Iodine Reaction . .441 

Perinuclear Basophilia 441 

Range of the Leucocytes in Pulmonary Tuberculosis . . 441 



TABLE OF CONTENTS. 



xxix 



Page. 



Range of the Leucocytes in Bone Tuberculosis . . . 441 
Range of the Leucocytes in Acute Miliary Tuberculosis, Tuber- 
culous Adenitis, Pleurisy, Peritonitis, Pericarditis, and Men 

ingitis, and in Genito -Urinary Tuberculosis . . . 443 

Effect of Secondary Septic Infections . . . . . 443 

Diagnosis . . . . . . . . . 443 

LXIII. Typhus Fever 444 

Parasitology . 444 

Hemoglobin and Erythrocytes 444 

Leucocytes ........... 445 

Diagnosis .......... 445 

LXIV. Vaccination 445 

LXV. Valvular Heart Disease 446 

Stage of Compensation ........ 446 

Acute Rupture of Compensation ...... 446 

Effect of Stasis ......... 446 

LXVI. Varicella . . 447 

LXVII. Variola 448 

Fibrin and Parasitology ....... 448 

Hemoglobin and Erythrocytes 448 

Leucocytes . . 448 

Blood Plaques 449 

Diagnosis 449 

LXVIII. Yellow Fever 449 

Fibrin and Coagulation 449 

Bacteriology . , 450 

Serum Reaction ......... 450 

Hemoglobin and Erythrocytes . . . . . . 450 

Degenerative Changes .451 

Leucocytes .451 

Differential Changes 45 1 

Diagnosis . . . . . . . . . 451 



LIST OF ILLUSTRATIONS. 



Plate. Page. 

I. The Erythrocytes . . . . . . . . 118 

II. The Leucocytes . . . . . . . ■ 154 

III. Leucocytosis ......... 176 

IV. Spleno-medullary Leukemia . . . . . . 246 

V. Lymphatic Leukemia ....... 256 

VI. The Tertian Malarial Parasite . . . . . . 362 

VII. The Quartan Malarial Parasite 366 

VIII. The Estivo-autumnal Malarial Parasite . . . . 371 

Chart. 

I. Pernicious Anemia . . . . . . . . 222 

II. Spleno-medullary Leukemia ...... 250 

III. Multiple Infections in Malarial Fever . . . . . 361 

Figure. 

1. Blood Lancet ......... 20 

2. Proper Distribution of Cells in a Blood Film . . . . 21 

3. Von Fleischl's Hemometer ....... 26 

4. Tinted Wedge of von Fleischl's Hemometer ... 26 

5. Capillary Pipette of von Fleischl's Hemometer ... 26 

6. Method of using the von Fleischl Hemometer ... 29 

7. Light-proof Box for von Fleischl's Hemometer ... 30 

8. Method of Using Oliver's Hemoglobinometer . . . 33 

9. Gower's Hemoglobinometer . . . . . . . 35 

10. Dare's Hemoglobinometer ....... 36 

11. Horizontal Section of Dare's Hemoglobinometer ... 37 

12. Method of Filling Blood Chamber ..... 38 

13. Thoma-Zeiss Hemocytometer . . . . . 42 

14. Thoma-Zeiss Counting Chamber ...... 43 

15. Ruled Area of Thoma-Zeiss Counting Chamber ... 44 

16. Ruled Area of Zappert's Counting Chamber .... 44 

17. Method of Filling the Hemocytometer ..... 45 

18. Plan of Counting the Erythrocytes . . . . . 48 

19. Ocular Diaphragm ........ 50 

20. Expelling Contents of the Erythrocytometer . . . . 52 

21. Cross Section of Durham's Blood Pipette . . . . 53 

22. Method of Using Oliver's Hemocytometer .... 57 

23. Superimposing the charged Cover-glass .... 59 

24. Drawing Apart the Cover-glasses ..... 60 

25. The Cover-glasses after Separation ..... 60 

26. Oven for Fixing Blood-films ...... 61 

xxx 



LIST OF ILLUSTRATIONS. 



xxxi 



Figure. Page. 

27. Daland's Hematocrit 73 

28. Engel's Alkalimeter 78 

29. Wright's Coagulometer 80 

30. Sorby-Beck Microspectroscope . . . * . . 81 

31. Sorby Tubular Cell . 82 

32. Needle and Tube for Aspirating Blood ..... 84 

33. Rouleaux Formation and Fibrin in Normal Blood . . . 101 

34. Hyperinosis . . . . . . . . 102 

35. Blood Spectra ' 125 

36. Degenerative Changes in the Erythrocytes . . . . 139 

37. Changes in the Erythrocytes in Chlorosis . . . . 210 

38. Changes in the Erythrocytes in Pernicious Anemia . . 221 

39. Atypical Myelocytes in Spleno-medullary Leukemia . . 253 

40. Atypical Polynuclear Neutrophils in Spleno-medullary Leukemia 254 

41. Atypical Lymphocytes in Lymphatic Leukemia . . . 259 

42. Positive Serum Reaction in Enteric Fever . . . . 319 

43. Pseudo-reaction in Enteric Fever ...... 320 

44. Bacillus Typhi Abdominalis . . . . . . 321 

45. Filaria Nocturna in Fresh Blood ...... 336 

46. Filaria Nocturna, showing Granular Degeneration . . 338 

47. Filaria Nocturna, showing Changes in Shape . . . 340 

48. Spirilla of Relapsing Fever . . . . . . . 418 



" L ' avenir appartient a V hematologic. C est elle qui nous apportera la 
solution des grands problemes nosologiques. Elle doit nous apparaiire comme 
une vaste science puisant ses materiaux dans loutes les branches des connais- 
sanccs biologiques et rectieillant les diverses notions de V hinnorisme ancien 
pour les rajeunir et les completer a la lumiere des decouvertes modernes en 
anatomie, en physiologie, en chimie biologique et en pathologic.'''' 

Georges Hayem. 



xxxii 



SECTION I. 



EXAMINATION OF THE BLOOD BY CLINICAL 
METHODS. 



2 



SECTION I. 



EXAMINATION OF THE BLOOD BY CLINICAL 
METHODS. 

~ A systematic examination of the blood by 

~ x ' clinical methods of established utility includes 

oCHEM A. 

the following twelve different processes : 
I. Microscopical examination of the fresh blood. 
II. Estimation of the percentage of hemoglobin. 

III. Counting the erythrocytes and the leucocytes. 

IV. Microscopical examination of the stained specimen. 
These four procedures, which invariably should be included in 

every clinical blood-report, furnish the most important informa- 
tion to be derived from hematological study, and are sufficient 
for routine clinical work. In certain instances in which more de- 
tailed investigation of special points is sought, it may be thought 
advisable to supplement the above plan by employing one or 
more of these remaining eight procedures : 
V. Counting the blood-plaques. 

VI. Estimation of the relative volumes of corpuscles and 
plasma. 

VII. Estimation of the specific gravity. 
VIII. Estimation of the alkalinity. 
IX. Determination of the rapidity of coagulation. 

X. Spectroscopical examination. 
XL Bacteriological examination. 
XII. Determination of the serum-reaction. 

I. EXAMINATION OF THE FRESH BLOOD. 

The finger-tip or the lobe of the ear is the part 
Obtaining usually selected from which to obtain the blood, 
the by puncture, for examination. The former site 

Specimen. is preferable in most instances, owing to its con- 
venient situation and ease of manipulation ; but 
in nervous individuals and in children the ear-lobe may be chosen, 
because of its limited sensibility, and on account of the patient's 
inability to watch the operation. 



20 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 



The puncture may be made with one of the special blood- 
lancets devised for this purpose, or, in lieu of such an instrument, 
a Hagedorn or spear-pointed surgical needle, or a new sharp- 
pointed steel pen from which one prong has been twisted off, will 
answer the purpose equally as well. The author is accustomed 
to use a small steel trocar-blade, mounted on a metal shaft which 
screws into an outer barrel, by means of a thread. By the use 
of a threaded locking-nut, any desired length of the trocar may 
be exposed, so that the depth of the wound may be controlled 
at will, irrespective of the force used to drive the point of the 
~ instrument through the skin. It is not 

necessary to sterilize the puncture- 
needle ; wiping it with a towel wet 
with alcohol is all that is required, 

Blood-lancet. . . . s^.r 

in ordinary examinations. Oi course, 
should the patient happen to be a syphilitic, it is safer to pass the 
blade through an alcohol flame, after having used it. 

Having chosen, say, the patient's middle or ring-finger, the 
part is first thoroughly cleansed with alcohol or ether and then 
with water, and wiped perfectly dry with a clean, lint-free towel, 
which may be then folded into a pad and slipped behind the fin- 
ger to isolate it from the neighboring digits, and to serve as a 
cushion for the back of the hand. The operator, holding the 
patient's hand in a firm, steady position, makes the puncture with 
a rapid motion of the wrist, such as one is accustomed to use in 
percussing the thorax, the depth of the wound being just suffi- 
cient to cause a free flow of blood in good-sized drops, unaided by 
the slightest pressure on the finger other than that necessary to 
start the initial oozing. The needle should be aimed so as to 
strike a point in the center of the flexor surface of the finger, just 
back of the extreme tip. The blood-drop to be used for the ex- 
amination should under no circumstance be squeezed from the 
finger, for blood secured in this manner is certain to be more or 
less highly diluted with lymph from the surrounding tissues — a 
condition which will give rise to erroneous results, especially to 
lower hemoglobin, specific gravity, and corpuscular estimations 
than actually exist. In severe anemias, especially in those of 
the pernicious type, the bloodless condition of the superficial ves- 
sels is sometimes so marked that it may be impossible to obtain 
enough blood for the examination by an ordinary puncture, even 
from the ear-lobe, which as a rule is highly vascular. Relatively 
deep incisions are unavoidable in such instances. On the con- 
trary in most cases of leukemia, unless the coexisting anemia 
is of striking intensity, the blood usually flows very freely, and 




EXAMINATION OF THE FRESH BLOOD. 



2 I 



may even spurt from the wound in a fine jet several inches in 
height. 

Most writers on hematology utter an emphatic warning against 
hemophilics, in whom the slightest prick of a needle may cause 
troublesome bleeding. The writer has never had the misfortune 
to nieet with this accident, but recognizes the wisdom of observ- 
ing the precaution habitually to question every patient concerning 
an abnormal tendency toward hemorrhage. 

The observer's attention should be directed to the color and 
the density of the blood drop as it flows from the puncture, and 
a note taken of the various macroscopical changes which may oc- 
cur, such as the pale, hydremic condition of the blood found in 
severe anemias, and the milky appearance of the drop in leu- 
kemia and in diabetes. These and other alterations in the naked- 
eye appearance of the fresh blood drop have been discussed in 
another section. 

The first few drops of blood which follow the 
Preparing puncture are wiped away, and the site of the in- 
the cision freed from every trace of moisture, after 

Slide. which a perfectly clean cover-glass, held edge- 
wise between the thumb and forefinger, is lightly 
touched to the summit of the next drop as it oozes from the 
puncture, and is then immediately placed, blood side downward, 



Fig. 2. 




Proper distribution of the corpuscles in a fresh blood-film prepared for 
microscopical examination. 

upon the surface of a clean glass slide. If the cover-glass and 
the slide are perfectly clean and dry, and if the drop is of the 



22 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 



proper size, the blood will at once spread out in a thin film con- 
sisting of a single layer of corpuscles. (Fig. 2.) Gently heat- 
ing the slide over an alcohol flame just before use will ensure a 
thin, even spread. If prolonged study of the specimen is intended, 
it may be advisable to exclude air from the film, by ringing the 
margins of the cover-glass with a thin layer of cedar-oil, or of 
vaseline, but ordinarily this precaution is unnecessary. In order 
to prevent distortion of the corpuscles, pressure must be avoided 
while adjusting the cover-glass. If the blood does not spread of 
itself, without the aid of pressure, it is usually owing to the pres- 
ence of particles of dust or grease between the opposed surfaces 
of the slide and cover-glass. 

Absolute cleanliness of the covers and slides is an essential 
detail to which too great attention cannot be paid, for neglect of 
this precaution is responsible for the majority of failures to secure 
good specimens. Perhaps the most useful cleansing agent is the 
solution popularly known as "acid alcohol " (hydrochloric acid, 
I part ; absolute alcohol, 29 parts ; water, 70 parts), which 
quickly and effectually removes all traces of grease and dirt from 
the glasses, so that their preliminary soaking in soap-suds or in 
a strong mineral acid, as some recommend, may be dispensed 
with. The slides and covers may be conveniently kept in closed 
glass receptacles containing this solution, from which they are 
removed as the occasion demands, being then dried and polished 
with a bit of clean linen, or with tissue-paper. Ordinary soft 
"toilet-paper" is excellent for this purpose. Oblong cover- 
glasses, measuring Jx i-J inches and of "No. 1 " thickness, are 
more easily handled without forceps than smaller square or cir- 
cular slips, and also have a much larger surface than the latter, 
which is often decidedly advantageous. 

The use of forceps is unnecessary, if care is observed to hold 
the cover-glass in the manner already directed, so that only its 
edges come in contact with the thumb and finger. 

The specimen, prepared in the manner just 
Microscopical described, is examined under the microscope 
Examination, with both low and high powers, a | or | inch 
dry, and a inch oil-immersion objective being 
the most satisfactory lenses for the purpose. The substage con- 
denser and diaphragm should be adjusted so that the field is but 
moderately illuminated, rather than flooded with a glare of white 
light. Microscopical examination of the fresh blood-film fur- 
nishes information about the following points : 

Changes Affecting the Erythrocytes. With a little practice, one 
soon becomes able to detect with a tolerable degree of accuracy 



EXAMINATION OF THE FRESH BLOOD. 



23 



any conspicuous decrease in the number of erythrocytes, by the 
relatively small number of cells in the field in comparison with 
their number in a similar field of normal blood. With less con- 
fidence, it is also possible to decide whether or not the number 
of erythrocytes is much in excess of the normal standard. 

Deficiency in hemoglobin produces unmistakable changes in 
the appearance of the cells, those in which this change is well- 
defined appearing as pale, washed-out bodies which stand in 
striking contrast to the darker, yellowish-green color of the nor- 
mal erythrocytes. 

Abnormal viscosity of the erythrocytes, their tendency towards 
rouleaux formation, the presence of deformities of size and of 
shape, and the occurrence of structural degenerative changes 
may also be distinguished in the fresh, unstained blood-film. 
Nucleated erythrocytes are not demonstrable in the fresh speci- 
men. 

Changes Affecting the Leucocytes. A glance is usually suffi- 
cient to determine whether or not the number of leucocytes is 
markedly in excess of normal, but too great dependence should not 
be placed on such a method of detecting the presence or absence 
of a leucocyte-increase, since it is at the best approximate, and 
sometimes erroneous. As will be explained elsewhere, any 
marked decrease in the number of erythrocytes, the leucocytes 
remaining normal, may so increase the ratio of the latter to the 
former, that the leucocytes may be apparently increased. 

Having tentatively determined that an increase in the total 
number of leucocytes is present, it is furthermore possible for 
one familiar with the morphology of the unstained leucocyte to 
make a fairly accurate differential count of these cells, and thus 
to decide whether the increase is due to a pure leucocytosis, or 
to some form of leukemia. This distinction is not at all diffi- 
cult in most instances, when one recalls the characteristics of the 
several forms of leucocytes in the fresh blood-film, viz.: small 
lymphocytes, large lymphocytes, and transitional forms, appear- 
ing as cells having a single, spherical, or indented nucleus, and a 
clear, shining, non-granular protoplasm ; polynuclearneutrophiles, 
as cells with polymorphous or multiple nuclei, and a protoplasm 
crowded with very fine, moderately refractive granules ; eosino- 
phils, as cells with a single, polymorphous nucleus, or multiple 
nuclei, and a protoplasm containing coarse, spherical, highly refrac- 
tive, fat-like granules ; and myelocytes as cells with a single 
spherical or ovoid nucleus, and a protoplasm crowded with very 
fine, moderately refractive granules. It is, of course, obviously 
impossible to distinguish basophile cells in the fresh blood, as 



24 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 



well as some of the cells containing fine eosinophile granules, 
but the characteristics noted above are sufficiently plain to justify 
at least a provisional diagnosis of either of the conditions in ques- 
tion, which, in every instance, should be verified by a careful ex- 
amination of the stained specimen. 

While most of the degenerative changes which affect the leuco- 
cytes are clearly demonstrable only in the stained specimen, it is 
still possible to recognize some of the grosser examples of such a 
process by a study of the fresh film. Vacuolation of both nucleus 
and protoplasm, extrusion of portions of the cell-substance, and 
the various stages of nuclear disintegration and of apparent solu- 
tion of the protoplasm are the alterations most commonly ob- 
served. In certain specimens " fractured" leucocytes are seen 
with more or less frequency, a cell thus affected being drawn out 
into a diffuse, irregularly shaped body with indistinct and ragged 
margins, about which the cell-granules, which have escaped from 
the protoplasm, are scattered in the form of a nebulous mass. 
The eosinophile leucocytes seem especially prone to undergo 
this disintegration. The exact significance of this phenomenon 
is not clear, but it probably represents a degenerative change in 
which the cells have become abnormally vulnerable, and thus 
highly susceptible to mechanical injury from the pressure of the 
cover-glass. 

Ameboid activity of the leucocytes, and pigmentation of these 
cells are among the other changes to be observed in a histolog- 
ical examination of the unstained blood-film. 

Increase in Fibrin, Blood-Plaques, and Hemoconia. The den- 
sity of the fibrin network and the rapidity with which it forms 
may be studied as coagulation of the blood-film progresses. 
Unless the blood-plaques are very greatly increased in number, 
they are not usually noticeable in the specimen prepared in the 
ordinary manner. The presence of hemoconia or " blood- 
dust" is at once rendered conspicuous by the rapid and incessant 
molecular motion with which these bodies are endowed. 

Blood Parasites. The hematozoa of the malarial fevers, the 
spirilla of relapsing fever, and the embryonic forms of the para- 
site of filarial disease should be studied in the fresh blood when- 
ever this is possible, rather than in the fixed and stained film, 
since in the latter the characteristic morphology of these parasites 
is greatly altered, and their motility lost. 

Foreign Bodies, such as free fat-droplets, collections of extra- 
cellular pigment, and, very rarely, the crystalline bodies of 
Charcot may also be observed in the fresh specimen, during the 
course of certain diseases. 



ESTIMATION OF THE PERCENTAGE OF HEMOGLOBIN. 25 

Microscopical examination of the fresh specimen should form 
the initial step taken in every systematic examination of the 
blood, since it may be the means of determining whether or not 
a more elaborate investigation is necessary. By this simple pro- 
cedure an immediate diagnosis may be made in a number of in- 
stances, while in others the findings, although not pathogno- 
monic, are of distinct clinical value. Close familiarity with the 
normal histology of the blood is, of course, essential for the ap- 
preciation of the various pathological changes which have been 
outlined above. Fuller reference to these changes has been 
made in other parts of this book. (See Sections III and IV.) 

II. ESTIMATION OF THE PERCENTAGE OF HEMO- 
GLOBIN. 

No less than half-a-dozen different hemoglo- 
Methods. binometers, or instruments for estimating the 
amount of hemoglobin in the blood, are in vogue 
at the present time, of which the most reliable for general 
clinical use are the instruments devised by von Fleischl, by 
Oliver, and by Gowers. The hemometer of von Fleischl has 
been the general favorite for a number of years, both in this 
country and on the Continent, but in England it has been sup- 
planted to some extent, first by Gowers' hemoglobinometer, and 
in recent years by the hemoglobinometer lately invented by 
Oliver. All three instruments are based upon a similar principle, 
that of measuring the depth of color of the diluted blood by a 
standard color-scale of varying intensity, the gradations of which 
correspond to different hemoglobin values. 

With this instrument, which is the one pre- 
von ferred by the great majority of clinicians, the color 

Fleischl's of a fixed volume of blood in an aqueous solu- 
Hemometer. tion of a definite strength is compared with the 
color of a movable glass wedge, tinted with Cas- 
sius' "golden purple." The hemometer consists of the follow- 
ing parts : 

(1) A tinted glass wedge, the thickest portion of which is of a 
deep pink color, and the thinnest portion almost colorless, with 
every intermediate color gradation between the two extremes. 
It is mounted in a metal frame provided with a scale, graduated 
at every five degrees from o to 120, the former corresponding to 
the thinnest, and the latter to the thickest part of the wedge. 
The metal frame is grooved so that it fits beneath (2) a small 



26 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 



Fig. 




Von Fleischl's hemometer. 



stage, in which it may be moved backward and forward by turn- 
ing a milled wheel. In the center of this stage there is a circu- 
lar opening through which the light of a candle is reflected by a 
disc of calcium sulphate, mounted on the pillar supporting the 

stage, like the mirror of a micro- 
scope. Back of this opening there 
is a small oval slot through which 
the scale of the underlying tinted 
wedge is visible, when the latter 
is adjusted to the stage. (3) A 
mixing chamber, consisting of a 
short metal tube closed at the bot- 
tom by a disc of glass and divided 
into two equal compartments by a 
vertical partition, fits accurately 
over the circular opening in the 
stage. When properly adjusted to 
the latter, the vertical partition 
exactly coincides with the upper 
edge of the underlying tinted wedge, so that the upper com- 
partment of the chamber is illuminated by the dull white light 
from the reflector, while the lower compartment receives the 
color of the tinted wedge. (4) A capillary pipette mounted in a 
short metal handle, used for 
making the blood dilution. 
A single pipetteful of nor- 
mal blood mixed with suffi- 
cient distilled water to fill 
exactly one of the compart- 
ments of the mixing cham- 
ber gives a solution which 
matches the color of the 
tinted wedge opposite the mark 100. (5) A small fine-pointed 
glass dropper, used*for filling with water the compartments. 

Method of Use. As a preliminary step, each 
compartment of the mixing chamber is filled 
about one-quarter full of distilled water, by 
means of the glass dropper to one end of which a 
rubber cap has been fitted. A puncture having 
been made, as previously directed, a measured 
volume of blood is collected by bringing one end of the 
capillary pipette lightly in contact with the blood drop, as it 
oozes from the wound, so that the tube is instantly filled with 
blood, by capillary force. No difficulty will be experienced 



Fig. 




Tinted glass wedge of the von Fleischl 
hemometer. 



Fig. 5. 



II 5.25 1 ' 1 



Capillary pipette 
of von Fleischl's 
hemometer. 



ESTIMATION OF THE PERCENTAGE OF HEMOGLOBIN. 2J 

in quickly filling the tube if it is applied horizontally to the 
side of the blood drop, rather than vertically to its summit, 
care being observed not to immerse the end too deeply. It 
is needless to add that the interior of the tube must be abso- 
lutely clean and diy, to insure which a very fine needle and 
thread may be passed through it just before using. As soon 
as the pipette is filled, every trace of blood must be removed 
from its outer surface, and the precaution taken to see that 
the column of blood is exactly flush with the ends of the tube, 
being neither bulged out nor depressed. The blood is then 
washed into one of the compartments of the mixing chamber, 
by forcing a stream of distilled water through the pipette by 
means of the glass dropper, this rinsing being repeated until it 
is certain that every trace of blood has been removed. The 
preceding steps must be carried out quickly, in order to avoid 
errors arising from coagulation of the blood. The blood and 
water in the compartment are now thoroughly mixed, by stir- 
ring with the handle of the pipette, until the color of the so- 
lution is uniformly diffused, after which water is added, drop 
by drop, to each compartment until they are both filled ex- 
actly to their brims. In doing this, no water must be spilled 
on the thin edge of the vertical partition, for should this 
occur it may cause an overflow of the liquid from one com- 
partment to the other, and thus alter the strength of the 
blood solution. If the latter should appear turbid, or muddy, 
as it sometimes does with leukemic blood, a few drops of a 
weak aqueous solution of potassium hydrate may be added to 
the diluent as a preventive of this change. The addition of a 
little ether will clear the solution, if the turbidity is due to the 
presence of fat. 

Having carried out the preceding steps, the mixing chamber is 
adjusted over the circular opening in the stage of the instrument, 
so that the compartment containing the blood solution is upper- 
most, overlying the semicircle illuminated by the clear, white 
light ; while the compartment filled with water fits over the semi- 
circle which receives the tint of the underlying glass wedge. 
The remainder of the test, the comparison of the color of the 
two compartments, must be completed by artificial light prefer- 
ably by candle-light. Moderately bright illumination is better 
than a strong glare, for the latter interferes seriously with the 
accurate determination of delicate color differences. By means 
of the milled wheel the tinted glass wedge is moved backward 
and forward until its color precisely corresponds to that of the 
diluted blood. When this occurs, the percentage of hemoglobin 



28 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

is read off from the scale visible through the oval slot in the 
stage of the instrument. 

While making the color comparison the observer should stand 
facing one end of the glass wedge (not the milled wheel), so that 
the partition between the two compartments of the mixing cham- 
ber is in a line with the vertical axis of his eyes, the distance from 
the latter to the top of the stage of the instrument being about 
ten or twelve inches. Gross errors may be avoided if the observa- 
tion is made with one eye, and if the same eye is habitually used, 
since the two eyes may differ radically in their sensitiveness to 
color impressions. It is important to decide the color differences 
as quickly as possible, for prolonged examination rapidly dulls 
one's color perception, and creates uncertainty as to the proper 
reading. It is a good plan first to bring into the field of vision 
the darkest portions of the wedge between the figures 100 and 
120 of the scale, and then, by short, sudden turns of the milled 
wheel, to produce abrupt color contrasts of from 5 to 10 de- 
grees at each turn, until the two tints approximately correspond. 1 
When this point is reached the eye should be rested for a few 
moments, and then, by a succession of shorter turns, the wedge 
is again swept to and fro until the colors appear identical. In 
the average instance an error of about 5 degrees must be antici- 
pated, in spite of every precaution to insure accuracy. 

In cases in which low hemoglobin percentages (30 per cent., 
or less) are suspected, it is essential to use two or three pipette- 
fuls of blood in making the dilution, dividing the percentage indi- 
cated by the instrument by two or three, as the case may be. 
This precaution effectually removes the objection which has been 
urged against this instrument on account of its inaccuracies in 
the determination of low hemoglobin percentages. Another 
criticism of the von Fleischl instrument has been made on the 
ground that, since the length of the tinted wedge visible through 
the compartment of the mixing chamber includes a color range 
of 20 per cent., it is impossible for one to select a single point in 
the center of this color for comparison with the even, diffuse tint 
of the blood solution. This objection may be overcome to a 
great extent by using a metal diaphragm, provided with a slit 
one-eighth of an inch in width, which is placed over the glass 
disc at the bottom of the compartments, to limit the field of 
vision. Adjusted so that the slit crosses at right angles the par- 
tition separating the two colors, the use of this device cuts down 

1 It is important to bear in mind the fact that the judgment of color differences is 
much easier if marked contrasts in color value are made, than if a gradual blending of 
the two tints is attempted, by slowly moving the wedge past the visual field. 



ESTIMATION OF THE PERCENTAGE OF HEMOGLOBIN. 



2 9 



the field of observation to a portion of the glass wedge corre- 
sponding to about 2.5 degrees on the scale. 

The hemoglobin percentages indicated by this instrument ap- 
pear to be low for the blood of the average healthy American, 



Fig. 6. 




Method of using the von Fleischl hemometer. 
Note that the septum between the two halves of the blood compartment is at right angles to the 
horizontal axis of the observer's eyes. A cylinder of paper may be fitted over the blood compart- 
ment, to serve as a camera-tube. 

since it is more common to obtain readings of from 90 to 95 than 
of the arbitrary standard 100, in persons in whom there is no 
good reason to suspect subnormal hemoglobin values. In in- 
struments of recent manufacture, however, this fault is largely 
corrected. 



30 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 



In order to exclude the light of the candle from the field of 
vision, while making the color comparison, it is customary to 
use a tube of cardboard or stiff paper, which is slipped over the 
mixing chamber, and rests upon the platform of the instrument. 
This sort of a device answers very well when the examination is 
made in a darkened room, as, for example, at a patient's residence. 
In hospital work, however, the inconvenience, sometimes con- 
siderable, of being compelled to carry the diluted blood some 
distance from the bedside to a dark-room may be avoided by the 
use of a light-proof box, which may be conveniently carried from 
ward to ward, so that the test may be completed at the bedside. 
(Fig. 7.) A box of this kind should measure sixteen inches 



Fig. 7. 




Light-proof box for the von Fleischl hemometer. 



The door of the box is closed and the color comparison made through the camera-tube. 

Note. — Reichert, at the suggestion of Miescher, has recently introduced a modifi- 
cation of the original von Fleischl hemometer, designed to increase the accuracy of 
the test, by making it possible, by definite dilution of the blood, to select that part 
of the tinted wedge which is best adapted for the examination of any particular sam- 
ple. This innovation was prompted by the discovery that the intermediate portions 
of the wedge are better adapted for obtaining accurate readings than the terminal 
parts. The principal modification of the new hemometer consists in the substitution 
for the original capillary blood pipette of a special mixing pipette, similar to a 
melangeitr, graduated so that the blood may be diluted I : 200, 1 : 300, and I : 400 
times. A table supplied with the instrument translates the combined results of the 
dilutions and the figures indicated by the scale on the wedge into absolute hemoglobin 
percentages. The instrument is also supplied with mixing chambers of different 
depths, and with a diaphragm designed to limit the field of vision. The writer has 
had no practical experience of the Miescher-Fleischl hemometer, but an examination 
of the instrument justifies the belief that its elaborateness renders it undesirable for gen- 
eral clinical work. Its cost ($50.00) is also a bar to many. 



ESTIMATION OF THE PERCENTAGE OF HEMOGLOBIN. 3 I 

in height by twelve inches in length and in width, being fitted 
with a hinged door which may be fastened shut by a simple catch, 
and provided with a circular opening through which the milled 
wheel of the hemometer projects when the door is closed. A 
metal camera-tube, flanged at the upper extremity for the obser- 
ver's eye, pierces the top of the box and communicates inside 
with the mixing chamber of the hemometer. The tube fits 
loosely in a circular opening in the top of the box, so that 
it may be readily raised and lowered ; its diameter is a trifle 
greater than that of the mixing chamber around which it should 
fit snugly when lowered into position ; and its length is governed 
by a fixed collar outside the box, which prevents it from slipping 
and jarring the instrument. Wooden guides, such as are used 
for securing a microscope in its box, are provided to receive the 
horseshoe base of the hemometer, holding it firmly in such a 
position that when the camera-tube is lowered into position, the 
milled wheel of the instrument projects through the opening in 
the closed door. The interior of the tube and of the box is 
painted a dull black. A candle is placed in position on the floor 
of the box, in a line with the 1 1 mirror " of the instrument. In 
using this device, first the candle within the box is lighted, and 
the hemometer base is slipped into place between the wooden 
guides. The blood dilution having been made in the usual man- 
ner, the mixing chamber is then set upon the platform of the in- 
strument, and the camera-tube which has been raised to allow 
this to be done, is lowered until it telescopes around the mixing 
chamber, and rests firmly upon its collar. The door of the 
box is now closed, and the two compartments are brought 
into their proper positions over the glass wedge by turning the 
camera-tube from the outside of the box, the observer mean- 
while noting the result by looking through the flanged ex- 
tremity of the tube. This accomplished, the projecting wheel of 
the instrument is turned to and fro until the colors of the two 
compartments are the same, when the door is opened, and the 
percentage read off from the scale of the hemometer. Care 
must be observed to see that the exterior of the mixing chamber 
is perfectly dry, for if any moisture collects between its outer sur- 
face and the inner surface of the camera-tube, the contents 
of the compartments may be disturbed and serious errors re- 
sult. As the opening in the door of the box is covered by the 
hand with which the milled wheel is turned, sufficient light to 
interfere with the test cannot leak in at this situation. 

With a light-proof box of this sort it is possible accurately 
to carry on hemoglobin estimations in the brightest daylight, 



32 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

which may be entirely excluded from the instrument, while the 
observer's field of vision is limited to the two semicircles illumi- 
nated by the candle burning within the box. 

With this instrument the principles of Lovi- 
Oliver's bond's tintometer are applied to the quantitative 
Hemoglobin- estimation of hemoglobin, the color of a blood 
ometer. solution of a definite strength being compared, 
by light reflected from a dead white surface, with 
a series of tinted glass standards which constitute a progressive 
color scale. Thus, a series of fixed, definite tints is provided, 
each of which accurately corresponds to the specific color-curve 
of progressive dilutions of normal blood, this having been de- 
termined individually, by means of the tintometer. Two sets 
of color standards have been devised : one for daylight readings, 
and one for observations by candle light, the latter being prefer- 
able on account of the greater delicacy of its readings. Oliver's 
complete apparatus consists of: (i) A capillary blood measure, 
made of heavy glass tubing, and having a capacity of 5 cubic 
millimeters. The end to be presented to the blood drop, in filling 
the measure, is tapered to a blunt point, and highly polished. 
(2) A mixing pipette, provided with a short rubber tube which 
fits over the tapered end of the blood measure, while rinsing out 
the blood from the latter into the (3) standard blood cell, which, 
when filled exactly to the brim with distilled water in which one 
measureful of blood has been dissolved, yields a blood solution 
of approximately one per cent. When filled, the cell is covered 
with a glass slip provided for this purpose. (4) A standard color 
scale, consisting of 12 tinted glass discs, mounted in two series, 
and corresponding to hemoglobin percentages ranging from 10 
to 120. (5) A set of riders, or squares of tinted glass, used for 
determining the intermediate degrees of color between the deci- 
mals indicated by the fixed tints of the scale. For ordinary clin- 
ical work two riders are sufficient, which when laid over the discs 
of the standard scale read 2.5 and 5 degrees respectively on its 
upper half, but double this amount on the lower half. For physi- 
ological observations requiring readings in units a set of nine riders 
is supplied. (6) A collapsible camera-tube, through which the 
color comparisons are made. 

Method of Use. In making hemoglobin estimations with 
Oliver's apparatus, first the capillary measure is filled with blood 
by the method directed for filling the pipette of the von Fleischl 
instrument. The rubber nozzle of the mixing pipette, previously 
filled with distilled water, is then adjusted over the polished end of 
the blood measure, and the blood washed into the standard cell by 



ESTIMATION OF THE PERCENTAGE OF HEMOGLOBIN. 33 

forcing through the water, drop by drop. As soon as all of 
the blood contained in the bore of the measure has been thus 
washed out into the cell, the rubber nozzle of the pipette is re- 
moved, and the handle of the measure used as a stirrer to mix 
the blood solution, more water being added in single drops, from 
time to time, until the cell is accurately filled. The blue cover- 
glass is then adjusted, with the result that, if the cell has not been 
overfilled, a small air bubble forms on the surface of the liquid. 
The blood cell, filled in this manner with a blood solution of 
definite strength, is now placed by the side of the standard 
scale opposite the tinted disc to which it corresponds most closely, 
the eye readily recognizing its approximate position on the scale. 
More accurate matching of the two colors is made with the aid 
of the camera-tube, the cell being moved from disc to disc in an 
endeavor to match exactly the color of the blood solution by one 



Fig. 8. 




Method of using Oliver's hemoglobinometer. 



of the standard tints of the scale. If this is successful, the hemo- 
globin percentage indicated by the disc is read off, and the obser- 
vation is completed. But if it happens that the tint of the blood 
solution is obviously deeper than a certain disc, but paler than the 
3 



34 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 



one immediately above, the cell is kept alongside the lower of the 
two, over which a rider is adjusted, in order to deepen its color, 
while the square of white glass is placed over the cell, so as to 
compensate for the thickness of the rider. If now the colors 
correspond, the final reading is ascertained by taking the percent- 
age of the disc plus the value of the superimposed rider. If the 
color of the blood solution is darker than that of any one of the 
standard discs, but paler than the disc plus a rider, the mean 
average of the two is taken as the final reading ; similarly, if the 
color of the blood solution is darker than a certain disc plus a 
rider, but paler than the disc immediately above, the values of 
the two must be averaged. An error of two per cent, is un- 
avoidable, even in the hands of a skilful observer. 

During the observation the candle should be placed three or 
four inches from the end of the color scale, being adjusted so that 
the flame is in a line with the opposed sides of the cell and of the 
scale, thus illuminating both with equal intensity. The positions 
of the candle and of the apparatus are shown in the accompanying 
illustration. (Fig. 8.) Small sized candles, such as are used 
for decorating Christmas trees, furnish a flame of the proper de- 
gree of brilliancy, the candle of ordinary size giving too intense a 
light. Total exclusion of daylight is not necessary, so that the 
observation may be made in the corner of a partly darkened 
room, as, for example, behind a closet door or some other similar 
shield against direct rays of light. 

Oliver's hemoglobinometer is a trial to the patience of one 
who has habitually used the von Fleischl instrument, and it takes 
some time to become accustomed to it after having worked with 
the comparatively simple color comparisons of the hemometer. 
But the results obtained with the newer instrument are so much 
more accurate than are possible with the older, that no one should 
hesitate in choosing Oliver's apparatus as the better of the two. 

This instrument, which for many years has 
Gowers' been popular in England and is used to some 
Hemoglobin- extent in this countiy, consists essentially of two 
ometer. small flattened tubes of equal diameter, which 
when in use are fixed upright and parallel to 
each other in a small wooden support furnished for this purpose. 
One tube contains glycerine jelly colored with picrocarmine to cor- 
respond to the tint of a I in 100 solution of normal blood (or, 
20 cubic millimeters of blood in 2 cubic centimeters of water), 
this being taken as the standard with which the blood solution, 
contained in the second tube, is compared. The second tube is 
provided with a scale graduated in units from 5 to 1 20, each de- 



ESTIMATION OF THE PERCENTAGE OF HEMOGLOBIN. 35 



gree of which equals the volume of blood required for the test. 
Twenty cubic millimeters of normal blood, dissolved in sufficient 
distilled water to fill this tube to the 100 mark on the scale, give 
a solution which corresponds to the tint of the 
standard tube. The special capillary pipette used 
for measuring the blood is graduated at 10 and at 
20 cubic millimeters, and fitted with a bit of rub- 
ber tubing and mouthpiece for filling it by suc- 
tion. 

Method of Use. The technique of hemoglobin 
estimations with Gowers' apparatus is extremely 
simple. Having made the puncture in the usual 
manner, the blood is sucked up the caliber of 
the capillary pipette until the mark 20 is reached, 
and then immediately blown out into the grad- 
uated tube, into which a few drops of distilled 
water previously have been placed, in order to 
insure instantaneous solution of the measured 
amount of blood. All traces of blood which Gowers' hemoglobi- 

NOMETER. 

may have adhered to the bore of the capil- 
lary pipette are removed by filling it several times with water, 
the rinsings being added to the mixture of blood and water in the 
tube. During the preceding steps the usual precautions must be 
observed, to wipe all surplus blood from the outside of the pipette 
before expelling its contents, and to measure the blood rapidly so 
as to guard against errors arising from rapid clotting. Distilled 
water is now added, drop by drop, to the mixture in the tube 
until the color of the blood solution exactly corresponds to that 
of the picrocarmine standard, the contents of the tube being mixed 
between each addition, by rapidly reversing it two or three times, 
with its open end closed by the thumb. The drop or two of 
liquid adhering to the thumb should be wiped off against the wall 
of the tube so that it may drain back into the liquid. When the 
tints of both tubes are precisely similar, the division of the scale 
to which the diluted blood reaches is read off, to express the per- 
centage of hemoglobin in the specimen under consideration. 

In comparing the colors, which is done by daylight, the tubes 
should be held against a sheet of white paper, or, as suggested 
by Gowers, between the eye and a window, and viewed at such 
an angle that their adjoining edges appear to overlap, thus cutting 
off the vertical streak of white light visible between them, should 
this precaution be neglected. Owing to the diagonal position in 
which the two tubes are adjusted in their support, the proper 
angle to produce this effect may be readily determined. 




36 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 



Fig. 10. 



The chief drawback to the use of this instrument is the liability 
to over-dilution of the blood after it has been mixed in the grad- 
uated tube, the occurrence of this accident necessitating, of course, 
a repetition of the entire operation. To the novice it is usually 
hard to decide just when sufficient water has been added to the 
blood to bring its color down to that of the standard tint, since 
one must depend solely upon a gradual weakening of the tint of 
the blood solution, and this is much more difficult than to com- 
pare a definite blood color with the sliding scale of the hemom- 
eter, or with the series of discs of the Oliver apparatus. The 
instrument may be regarded as accurate within 2 or 3 per cent, 
for hemoglobin percentages above 10, below which figure it is 

impossible to distinguish a 
difference between the tints 
of the two tubes. This 
source of error, however, is 
too remote a possibility to 
detract from the instru- 
ment's practical value. 

Dr. Ar- 
Dare's thur Dare, 
Hemoglobin- of the Jef- 
ometer. fersonHos- 
pital Med- 
ical Clinic, has recently de- 
vised a new form of hemo- 
globinometer, by the use 
of which a thin film of un- 
diluted blood is brought 
into direct comparison with a 
standard semicircularwedge 
of tinted glass ranging in 
color from a claret red at 
the thickest part, to a pale 
pink at the thinnest. The 
instrument consists of the 
following parts : (1) A cap- 
illary blood chamber, con- 
structed of two rectangular plates of polished glass, the opposed 
surfaces of which are so ground that, when clamped together in 
a metal bracket, a shallow compartment holding a thin film of 
blood is formed. One plate is made of transparent, the other of 
opaque glass, the latter being next to the source of light, in order 
to soften its glare, when the instrument is in use. The metal 




Dare's hemoglobinometer. 

R, milled wheel acting by a friction bearing on the 
rim of the color disc ; S, case enclosing color disc, and 
provided with a stage to which the blood chamber is fit- 
ted ; T, movable wing which is swung outward during 
the observation, to serve as a screen for the observer's 
eyes, and which acts as a cover to enclose the color disc, 
when the instrument is not in use ; U, telescoping camera- 
tube, in position for examination ; V, aperture admitting 
light for illumination of the color disc; X, capillary 
blood chamber adjusted to stage of instrument, the slip 
of opaque glass, W, being nearest to the source of light ; 
Y, detachable candle-holder ; Z, rectangular slot 
through which the hemoglobin scale indicated on the 
rim of the color disc is read. 



ESTIMATION OF THE PERCENTAGE OF HEMOGLOBIN. 



37 



bracket of the blood chamber is adjusted to the stage of the in- 
strument in such a manner that the blood-film fits over an aper- 
ture communicating with a camera-tube screwed to the op- 
posite side of the rubber case. (2) A graduated color standard 
made of a semicircle of glass tinted with Cassius' "golden- 
purple," and thinning out like a wedge with various depths of 
color corresponding to the tints of fresh blood containing dif- 
ferent percentages of hemoglobin. It is mounted upon a disc ad- 
justed in the frame of the instrument so that it may be revolved 
to bring various portions of its surface over an aperture directly 
alongside of the one through which the blood film is vis- 
ible. A scale, read from the outside of the instrument, in- 
dicates in units the hemoglobin percentages from 10 to 120. 

case encloses the color standard, when 
use, the disc upon which the standard is 
a small milled wheel acting 

upon the rim of the disc by a 



m 

(3) A hard ruooer 
the instrument is in 
mounted being revolved by turning 

friction 



bearing. To one side 



Fig. 11. 



of the case a 
telescopic camera-tube, fitted with an 
eye-piece, is attached, while on the 
opposite side a stage furnishes support 
for the blood chamber, back of which 
a candle, held between a pair of spring 
clips, is adjusted. Two apertures of 
equal diameter, placed side by side 
on the same level, transmit the light 
of the candle through the blood-film 
and the color standard to the field of 
vision enclosed by the camera-tube. 
By reference to the accompanying 
diagram (Fig. 11), it will be seen that 
the light of the candle, J, equally illu- 
minates the blood film enclosed be- 
tween the two rectangular glass plates, 
O and P, and the edge of the color 

standard, L, mounted upon the glass disc, K. The differences 
in the two colors are visible through the two apertures, M and 
M', communicating with the camera-tube, N. By 
the disc the tint of the color standard may be altered unti 
matches that of the blood-film. 

Method of Use. The instrument is prepared for use by first 
swinging outward the movable screen which serves as a cover for 
the case. The two apertures overlying the blood-film and the 
color scale are thus brought into view, the direct light from the 




Horizontal section of Dare's 
hemoglobinometer. 



revolving 



it 



38 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 



candle being shaded from the observer's eyes by the intervening 
screen. The camera-tube and the candle-holder are then fitted to 
their attachments on opposite sides of the instrument, and a candle 
adjusted so that the surface of its " wick end" is just on a level 
with the top of the spring clips. 

The blood chamber is filled by touching its edge to the side of 
a rather large drop of blood, as the latter flows from the punc- 
ture, so that the blood 
at once flows into and 
fills, by capillary force, 
the shallow compart- 
ment between the pair 
of glass plates. As 
soon as this occurs, 
any excess of fluid 
which may have ad- 
hered to the outer sur- 
face of the blood cham- 
ber is carefully wiped 
away, and the latter 
is slipped into the tongue which holds it in position on the stage 
of the instrument. 

The candle having been lighted, the observer holds the instru- 
ment as a field glass, and compares with one eye the colors of 
the blood-film and the standard disc which are seen side by side 
in the field of vision limited by the camera-tube. The disc is 
made to revolve by making short, quick turns with the milled 
wheel, until the two colors are identical, and the hemoglobin 
percentage indicated by the scale is then noted. 

The color comparisons need not be made in a darkened room, 
although the observer should avoid facing the direct sunlight, 
and, in order to exclude reflected light, should hold the instru- 
ment against a dark surface, such as a black coat sleeve. When 
the observation is completed, the two glass plates of the blood- 
chamber are removed from the bracket by loosening the screw 
which holds them in position. They are then cleaned with water 
and with acid alcohol, dried, polished, and replaced in the bracket. 
The various parts of the instrument, when detached, fit into a small 
leather carrying-case. 

The chief advantage of Dare's instrument lies in the fact that 
dilution of the blood is not required, and therefore errors due to 
incorrect measuring and dilution of the blood, which must be care- 
fully guarded against in the older hemoglobinometers, are entirely 
eliminated. A film of whole blood also gives a relatively deep 




ESTIMATION OF THE PERCENTAGE OF HEMOGLOBIN. 



39 



and definite color, which may be judged with greater ease and 
accuracy than the paler and more indefinite tint of a blood solu- 
tion. It is also obvious that errors due to the turbidity of an 
aqueous solution of leukemic blood, are avoidable by the use of 
an undiluted film. Coagulation of the film does not occur with suf- 
ficient rapidity to constitute a source of error, since the test may 
be completed within a few seconds after the blood has been drawn. 

One year's more or less constant use of this instrument in the 
Jefferson Medical Clinic has shown that its readings closely cor- 
respond to those of Oliver's hemoglobinometer, and average some- 
what higher than those of the von Fleischl instrument. The color 
standard of Dare's apparatus, being wedge-shaped, and therefore 
gradually blending the tints, is open to the same criticisms which 
have been urged against the scale of the hemometer. 

A simple method of approximately determin- 

Tallquist's ing hemoglobin percentages without the aid of 
Method. a special instrument has recently been devised 
by Tallquist, 1 the procedure consisting, in brief, 
in allowing a drop of blood to soak into a bit of filter-paper and 
comparing with the naked eye the color strength of the stain 
with a series of printed standard tints of known value. The lat- 
ter are arranged as a scale of ten different colors corresponding 
to the colors of stains produced by bloods having hemoglobin 
values ranging from ioto 100 per cent., the latter being regarded 
as the normal. A lithographed copy of the color standard ac- 
companies Tallquist's original article. The test is made in the 
following manner : A drop of blood, large enough to make a 
stain about five or six millimeters in diameter, is caught in the 
center of a piece of white filter-paper, care being taken in col- 
lecting it to apply the paper to the exuding drop in such a man- 
ner that the blood soaks in very slowly, and thus produces a 
stain which is evenly colored throughout. Perfectly white filter- 
paper having a smooth surface, and of a thickness corresponding 
to about fifty-five leaves to the centimeter, should be used for the 
test. The blood stain thus made is pressed lightly against a pad 
of filter-paper, and then compared, by direct daylight, with the 
series of standard tints, the figure opposite to the tint which the 
stain most accurately matches being read off, to indicate the per- 
centage of hemoglobin in the specimen under examination. The 
comparison must be made immediately after the stain loses its 
humid gloss, since blood soon changes its color after exposure to 
the air. 

This direct method of hemoglobin testing is, of course, only 

1 St. Paul Med. Journ., 1900, vol. ii.,p. 291. 



40 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 



approximate, at the best, and cannot be expected to furnish re- 
sults comparable in point of accuracy with those to be obtained 
by any of the instruments just described. It may, however, be 
employed to excellent advantage when a hemoglobinometer is 
not at hand, or in certain cases in which only a rough estimate of 
the amount of coloring matter of the blood is sought. Tall- 
quist, who has tested his method under the control of the he- 
mometer, in his clinic at Helsingfors, claims that the limit of error 
generally does not exceed ten per cent. 

III. COUNTING THE ERYTHROCYTES AND THE 
LEUCOCYTES. 

Of the various instruments used for counting 
Methods. the blood corpuscles, the hemocytometers de- 
vised by Thoma and by Gowers are most gener- 
ally employed at the present time, the former being used almost 
to the exclusion of the latter everywhere except in England, 
where Gowers' apparatus has many firm adherents. Durham, 
by adapting and modifying a number of the details of the older 
instruments, has succeeded in devising an improved form of hemo- 
cytometer which possesses many advantages over the original 
models, being of simple construction, accurate, and comparatively 
inexpensive. The method of making the estimate, which is es- 
sentially the same with all three of these instruments, consists, 
briefly, in first diluting the fresh blood in definite proportions with 
some indifferent preservative fluid, and in then counting, under 
the microscope, the number of corpuscles in a drop of the di- 
luted blood, the latter being contained in a small glass cell on 
the floor of which is ruled a series of micrometer squares of cer- 
tain dimensions. The cubic contents of the cell and the degree 
of the blood dilution being known, the number of corpuscles 
counted in any given number of these squares may be taken as 
a basis for calculating the total count of corpuscles to the cubic 
millimeter of blood. 

In addition to the method of actually counting the corpuscles in 
a known volume of diluted blood, Oliver has devised an instru- 
ment with which the number of erythrocytes may be estimated 
by means of their optical effect, without the use of the microscope. 

Diluting fluids for use with the hemocytom- 
D i luting eters of Thoma, Gowers, and Durham should 
Fluids. be of such a composition that when mixed with 
the fresh blood they preserve unaltered the form 
of the corpuscles. This requirement being met, the examiner 



COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 4 1 



may choose from the numerous formulae in current use the one 
which best suits his individual preference. Among the most sat- 
isfactory solutions used for this purpose the following may be 
mentioned : 

Toisson's Solution. 

Methyl-violet, 5 B 0.025 

Sodium chloride i.o 

Sodium sulphate , . 8.0 

Neutral glycerine 30.0 

Distilled water. 160.0 



Sherrington's Solution. 

Methylene-blue o. 1 

Sodium chloride 1.2 

Neutral potassium oxalate 1.2 

Distilled water 300. o 

For general clinical work no better formulae have ever been 
suggested than the preceding two. Both solutions act as excel- 
lent preservative fluids, and each contains just sufficient quantity 
of a basic aniline dye to stain the leucocytes with great distinct- 
ness, so that they may be readily differentiated from the erythro- 
cytes, which remain uncolored. 

Hayem's Solution. 



Mercuric chloride 0.25 

Sodium chloride 0.5 

Sodium sulphate 2.5 

Distilled water 100.0 



Oliver specifies this solution as the diluent invariably to be 
employed with his instrument, but it may be used also with the 
other forms of hemocytometers, although with less satisfaction 
than the formulae first mentioned. 

Among the simpler diluting fluids, all of which are depend- 
able, are solutions in distilled water of common salt (0.7 per cent.), 
of potassium bichromate (2.5 per cent.), and of sodium sulphate 
(5 per cent.), to any of which about 0.5 per cent, of an alco- 
holic solution of methyl-violet may be added, in order to stain 
the leucocytes, and thus to facilitate the counting. 

An aqueous solution of acetic acid, varying in strength from 
0.3 to 0.5 per cent., which destroys the erythrocytes and at the 
same time renders more conspicuous the leucocytes, has been 
recommended by Thoma as a diluent in counting the latter cells, 
by means of his special pipette. 



42 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 



The Thoma- 
Zeiss Hemo- 
cytometer. 



Fig. 



As spores are liable to develop and precipitates to form in all 
the above-mentioned solutions, they should always be filtered 
before using, and kept in tightly corked bottles. 

The Thoma-Zeiss hemocytometer, which is 
to-day regarded as the standard instrument for 
blood counting, consists of two graduated capil- 
lary pipettes, for diluting and mixing the blood, 
and a counting chamber in which a measured 
volume of diluted blood is placed for the purpose of counting the 
corpuscles under the microscope. One of the pipettes is intended 
for counting the erythrocytes, and, for con- 
venience's sake, may be termed the erythro- 
cytometer ; while the other pipette, which is 
used for counting the leucocytes, may be 
called the leucocytometer. It is not, however, 
necessary to purchase both pipettes, as sup- 
plied with the complete apparatus, since both 
eiythrocytes and leucocytes may be counted 
accurately with the erythrocytometer. 

The erythrocytometer consists of a heavy 
glass capillary tube, the lumen of which is 
expanded near the upper end into a bulb con- 
taining a small cubical glass bead, which 
serves as a stirrer. The lower end of the tube 
is ground to a blunt point, and to the upper end 
is fitted a short bit of rubber tubing capped by 
a bone mouthpiece, for filling the tube by suc- 
tion. A scale is enameled into the glass wall 
of the pipette, the three main divisions of which 
are indicated by the figures, 0.5, 1, and 101, 

fthe first two gradations being below, and the 
t latter one above, the bulb ; the lower portion 
I of the tube is further graduated in tenths, by 
cross lines, from 0.1 to 1. If blood is drawn 
up in the pipette to the mark 1 , and the diluent 
added until the mark 101 is reached, the blood 
is thus diluted one hundred times ; or if the 
blood is drawn up only to the mark 0.5, and 
the diluent added as before, a two hundred-fold 
dilution is obtained. 

The leucocytometer is a capillary tube similar 
to the former, but having a larger lumen, so 
that lowe r dilutions are obtained with it. If blood is drawn up to 
the mark 1, and the diluent added until the mixture reaches the 



The Thoma-Zeiss 
hemocytometer. a, 
erythrocytometer; B, 

LEUCOCYTOMETER. 



COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 43 



mark 1 1, the blood is diluted ten times ; or if the blood column 
reaches the mark 0.5, with the same addition of diluent, the dilu- 
tion thus made is twenty-fold. In the latest model of this pipette 
the lower end tapers to a fine point, the diameter of the lumen 
thus gradually decreasing as the extreme tip is approached. The 
chief object of this modification is to prevent accidental leaking 
out of the column of blood when the tube is held vertically, while 
sucking up the diluting fluid — an accident difficult to avoid with 
the old-style pipette, having a large lumen from tip to bulb. 

The coimting chamber (Fig. 14) consists of a heavy glass slide in 
the center of which is cemented a square glass plate provided with 
a circular opening which fits around a ruled disc ; the diameter of 
the latter being slightly less than that of the opening in the sur- 
rounding plate, a shallow, narrow gutter is thus formed between 
the two. The surface of the ruled disc is exactly millimeter 
below the level of the glass plate by which it is enclosed, so 



Fig. 14. 




Thoma-Zeiss counting chamber. 



that a chamber of this depth is formed when both are superim- 
posed by a cover-glass having an absolutely plane surface, two of 
which are furnished with each instrument. An ordinary cover- 
glass should never be used, for owing to the unevenness of its 
surface a deviation from the standard in the depth of the underly- 
ing chamber must necessarily result. When an objective having 
an extremely close " working distance" is employed, the special 
hollow-cell cover-glass, made by Zeiss, will prove useful. 

The central part of the disc's surface is divided, by microscopical 
diamond-rulings, into 400 small squares, each of which has an area 
of ^-i-o square millimeter, these small squares being grouped into 
sets of sixteen, by a series of vertical and horizontal double rul- 
ings bisecting each fifth column of squares. (Fig. 15.) The 
cubic contents of each small square, when the cover-glass is ad- 
justed, is ^qVo cu bic millimeter, since they measure individually 



44 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

To To ky 2V m iHimeter. In Zappert's modified ruling of the 
Thoma-Zeiss counting chamber, extra lines have been added so as 

Fig. 15. 




Ruled area of the Thoma-Zeiss counting chamber (ordinary ruling). 

to increase the ruled area of the disc to nine times its original 
size. As illustrated in the accompanying diagram (Fig. 16), the 

Fig. 16. 

























































|fi±5||!S^||||| EE 































Zappert's modified ruling of the Thoma-Zeiss counting chamber. 

surface of the disc is thus divided, by heavy cross-rulings, into nine 
large squares each equal in area to the central group of 400 small 



COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 45 



squares, the whole ruled surface therefore equalling an area covered 
by 3,600 of the latter. To simplify the counting, the peripheral 
squares are subdivided into four, each of the latter being of the 
same area as 100 of the small central squares. . This improved form 
of counting chamber is an invaluable convenience in leucocyte 
counting, and should be chosen in preference to the older model. 

If any difficulty should be experienced in distinguishing the 
ruled lines under the microscope, they may be made more con- 
spicuous by blackening them with a little soft lead pencil dust, 
placed on the surface of the disc and thoroughly rubbed in with 
the pulp of the finger, the excess being wiped off and the disc 
polished with a bit of lens-paper, or a soft handkerchief. 



Fig. 17. 




Method of filling the capillary tube of the Thoma-Zeiss hemocytometer with blood. 

Counting the Erythrocytes. Having made the puncture, as 
already described, the point of the erythrocytometer is plunged 
into the blood drop, as it flows from the wound, and, by making 
gentle, uniform suction, a column of blood is drawn up the capil- 
lary tube exactly to the mark 0.5. The point of the instrument 



46 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

is then wiped perfectly diy, and immediately dipped into the diluting- 
fluid, which is drawn up the tube in the same manner until the 
mixture of blood and diluent reaches the mark 101, above the 
bulb. While adding the diluent, the pipette should be twisted to 
and fro between the thumb and forefinger, in order that the blood 
and diluent may be mixed, by the whipping about of the glass 
bead, as they fill the bulb ; if this precaution is neglected, a por- 
tion of the blood will rise in a distinct layer above the diluent, as 
the latter flows into the bulb, and may be drawn, unmixed, into 
the capillary constriction beyond. A more thorough mixture of 
the blood and diluent is now made, the rubber tubing being 
slipped from the instrument, which is then grasped so that its 
ends are closed by the thumb and middle finger, and rapidly 
shaken for about half-a-minute. By the above steps, a mixture 
is made in which the proportion of blood to diluent is 1 : 200, a 
degree of dilution with which it is most convenient to work, in 
the great majority of instances. For two reasons a 1 : 200, rather 
than a 1 : 100, dilution is to be preferred in routine work: (1) 
If, as not infrequently happens, the blood column is accidentally 
drawn up the tube beyond the mark 0.5, in an attempt exactly 
to reach this gradation, it is a simple matter to correct the error 
by gently blowing or shaking the blood column down to the 
proper height ; whereas, in attempting to make a 1 : 100 dilution, 
should the mark 1 be exceeded, the blood column will almost 
surely escape into the bulb whence it cannot be blown back again 
into the capillary tube, thus necessitating a repetition of the 
whole operation with a fresh drop, after having cleaned and dried 
the erythrocytometer. (2) It is easy to count the corpuscles 
in a 1 : 200 dilution, since the surface of each ruled square of the 
counting chamber is, as a rule, occupied by not more than half 
a dozen cells ; on the contrary, in a 1 : 100 dilution, except in 
an occasional instance in which there is a striking paucity of cells, 
the field may be so overcrowded with corpuscles that their enu- 
meration is difficult, and often inaccurate. 

The next step is to place a drop of the diluted blood in the 
counting chamber, preparatory to counting the corpuscles under 
the microscope. The unmixed diluting fluid in the lower portion 
of the capillary tube is first expelled, by blowing out four or five 
drops, after which the point of the pipette is dried with a soft 
cloth, and a small drop of the blood mixture is allowed to fall, 
by force of gravity, exactly in the center of the surface of the 
ruled disc. The cover-glass is then immediately placed in posi- 
tion, and the slide left undisturbed for several minutes, so that 
the corpuscles may settle. The drop placed on the disc should 



COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 47 

be of sufficient size to occupy only its central portion, the object 
being to use just enough of the blood mixture to cover the ruled 
area and exactly to fill in the vertical space between the surfaces 
of the disc and cover-glass when the latter is placed in position. 
' If the drop contains air-bubbles, or if it is so large that it over- 
flows into the gutter and perhaps finds its way between the cover- 
glass and the glass plate beneath, errors will result, so that in 
event of either of these accidents the procedure must be repeated 
with another drop, after having cleaned and dried the cover-glass 
and the counting chamber. Water, and not alcohol or xylol, is 
to be used for this purpose, since the repeated use of chemicals 
will soon dissolve the cement which fixes the disc to the counting 
chamber. In repeating the operation the original technique must be 
rigidly followed, i. e., the erythrocytometer must be briskly shaken 
for half a minute or so, and the contents of its capillary stem blown 
out, before placing the new drop in the counting chamber. 

In a properly prepared slide concentric rings of color — New- 
ton's rings — may be seen at the points of contact between the 
cover-glass and the underlying glass plate. If these rings are in- 
visible, or if they do not appear when pressure is made upon the 
cover-glass, it is a sign that the contact between the two glass 
surfaces is not true, this being due to the presence of particles of 
dust or of moisture beneath the cover-glass. Inasmuch as this may 
seriously affect the correctness of the count, it is a safe rule invari- 
ably to reject a slide in which these color rings are not visible. 

As soon as sufficient time has elapsed for the corpuscles to 
sink to the bottom of the counting chamber — about five minutes 
— the slide is transferred to the stage of the microscope, which 
should not be inclined, for fear of disturbing the uniform distribu- 
tion of the cells. The field is first brought into focus with a low- 
power objective (a No. 3 objective of Leitz, for example), and the 
slide moved across the stage until the extreme upper left-hand 
corner of the group of small ruled squares is brought into view, 
when a higher power, to be used in counting, is substituted. 
For this purpose the writer is accustomed to use a Leitz No. 6 
objective and No. 4 ocular, which lenses, with a tube length of 
155 mm., cut off a field occupied by a block of 25 small squares. 

As a basis for the final calculation, the erythrocytes in 400 
small squares, or the entire ruled surface of the old-style disc, 
should be counted, preferably by going over two groups of 200 
squares each in two different drops, rather than by taking the en- 
tire 400 squares in a single specimen. By following this plan the 
count of one drop may be " controlled " by the count of the other, 
and any discrepancy between the two discovered, for if the dif- 



48 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 



ference in the counts is striking, a third group of 200 squares 
must be examined in an additional drop, and an average taken 
of the two counts which most closely correspond. 

In order to simplify the process of counting, some routine 
method of examining the ruled area, such as the following, should 
be adopted : Beginning at the upper left-hand corner of the ruled 
disc, the corpuscles in the first 100 small squares are counted, 
the slide being moved from above downward, preferably by the 
aid of a mechanical stage, as the successive groups of squares are 
covered. By employing the magnification to w r hich reference has 
just been made, three shifts of the slide are sufficient to bring 
into the field the requisite number of squares in blocks of 25 
each. Examining each small square in succession, proceed from 
left to right along one row of five, then drop to the next row and 

Fig. 18. 




Plan of counting the erythrocytes. 

The small squares are examined in the order indicated by the arrow, successive blocks of 25 squares 
being covered until the required number of cells has been counted. 



count from right to left, and continue in the manner illustrated 
by the diagram (Fig. 18) until all the erythrocytes in the first 
group of 100 squares have been counted, the totals of each block 
of 2 5 squares being noted as they are completed. To avoid repe- 
tition in counting it is necessary to include in the total all the cor- 
puscles which touch the upper and left boundary lines, and to 
disregard those which touch the lower and right boundaries. A 
second group of 100 squares, not immediately adjacent to the 



COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 49 



first, is then inspected in a similar manner, after which the cover- 
glass and counting chamber are washed with water and dried, and 
the operation repeated with a second drop. Thus the 400 squares 
are covered by examining 16 blocks of 25 squares each, 8 in the 
first, and 8 in the second drop of diluted blood. In a 1 : 200 di- 
lution of normal blood this involves the counting of approxi- 
mately from 2,400 to 2,800 erythrocytes, and gives results which 
are accurate within one-and-one-half per cent. 

To calculate the number of erythrocytes to the cubic milli- 
meter of blood, the following formula is employed : 

Number of erytli- Degree of dilu- Cubic contents Total num- 
rocytes counted x tion (200) x of each square beroferyth- 



For example, supposing that in the 400 squares of a 1 : 200 
blood dilution a total of 2,500 erythrocytes is counted, the cal- 
culation is made thus : 

. 2,500 x 200 x 4,000 

(a) ~^oo = 5>° 00 > 000 erythrocytes per co. mm. 

(b) 2,500 x 2,000 = " " " " " 

Counting the Leucocytes. The leucocytes may be counted by 
two different methods : (a) with the erythrocytometer, in the 
same drop of diluted blood in Avhich the erythrocytes are esti- 
mated ; or (b) with the special leucocytometer, as a separate pro- 
cedure. Of the two methods the former is greatly to be preferred, 
since it is fully as accurate, and much more convenient and time- 
saving than the latter. Furthermore, there is an undoubted ad- 
vantage in counting both the red and the white corpuscles in the 
same drop of the blood dilution. 

(a) If the leucocytes are counted with the erythrocytometer 
the same technique is followed as in determining the number of 
erythrocytes, except that a much larger area of the counting 
chamber must be examined, owing to the comparatively small 
number of leucocytes contained in the 1 : 200 blood mixture. 
It is necessary, for the sake of accuracy, to. count the leucocytes 
in the entire space enclosed by Zappert's ruling, and to repeat the 
count in a second drop, making an area equal to eighteen times 
the ruled space of the old-style counting chamber to be examined. 
If the totals of both counts are approximately the same, their 
combined figures, representing the corpuscles found in a space 
corresponding to 7,200 of the small ruled squares, is taken as a 
basis for the final estimate ; but if these totals widely differ, a 




(4,000) 



rocytes per 
cb. mm. 



Nimiber of squares counted (400) 



4 



50 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 



third drop is to be examined in the same manner, and, as in 
counting the erythrocytes, an average taken of the two totals 
which are nearest alike. Since in normal blood, in a I : 200 
dilution each block of 400 small squares contains from 3 to 6 
leucocytes, the examination of the above-mentioned area of the 
counting chamber involves the counting of approximately from 
54 to 108 of these cells — an operation which, practically, is not 
nearly so laborious as it appears from the description, being 
easily completed within ten or fifteen minutes, in most cases. 1 

As an example of the method of calculating the final estimate, 
supposing that 90 leucocytes have been counted in the area equal 
to 7,200 small squares, the blood dilution being 1 : 200, this for- 
mula is employed : 

90 x 200 x 4,000 7,200 = 10,000 leucocytes per cb. mm. 

If the old-style counting chamber is used, the leucocytes in the 
unruled portion of the disc outside of the central block of 400 
squares may be counted with the aid of an eye -piece diaphragm, 
which when adjusted inside the tube of the ocular cuts off a field 
exactly the size of 100 small squares (Fig. 19). A black metal 
or cardboard disc having a central aperture 
Fig. 19. 0 f p ro per size will answer just as well for 

J^SSK&k. this purpose as the more expensive and elab- 
orate mechanical eye-piece devised by Ehrlich, 
which is provided with a diaphragm having a 
square opening the size of which is regulated 
by a small lever. Having first counted all the 
N! ^l|jJ|j||P^ leucocytes in the 400 small squares, the cells are 
ocular diaphragm. then counted in 3 2 of the diaphragm-fields out- 
side the latter, in order to cover an area of the 
disc corresponding to the entire ruled surface of the Zappert count- 
ing chamber. This operation having been repeated in a second 
drop, the totals of both counts are taken as the basis for the final 
calculation, which is made in the manner already described. 

If one happens to possess neither an eye-piece diaphragm nor 
a Zappert counting chamber, the following method of calculat- 
ing the cubic contents of the portions of the disc outside the 
ruled area may be adopted, as advised by Stengel. 2 1 Using, for 
example, a -1-inch objective and a i-inch ocular, the ruled lines 
are brought into focus, and the tube of the microscope drawn 
out until one of the parallel lines of the ruled disc exactly coin- 
cides with either boundary of the field of vision. Assuming that 8 of 

1 Should the leucocytes be decidedly increased, it is unnecessary to cover such a 
large number of squares. One hundred cells taken as a basis for the calculation will 
give an accurate estimate. 

2 "Twentieth Century Practice of Medicine," N. Y., 1896, vol. vii., p. 271. 



COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 5 I 



these parallel columns, each fa millimeter in width, are included 
in the visual field, the diameter of the latter is therefore fa or | 
millimeter, and the radius one-half of this figure, -fa or i milli- 
meter. The area of the field may then be readily determined by 
multiplying the square of its radius by 3 . 141 6. Its cubic contents 
are obtained by also multiplying by -fa millimeter, formula being : 

i X -4- x -fa x 3 • 1 4 1 6 = .0125 664, cubic conten ts of the visual field. 

Having in this manner ascertained the cubic contents of each 
field of vision, the final calculation of the number of leucocytes 
to the cubic millimeter of undiluted blood is made by multiply- 
ing the total number of these cells found in a definite number of 
fields ( for instance, 50) by the degree of dilution (usually 1:200), 
and by then dividing by the cubic contents of each field (.0125- 
664) multiplied by the number of fields examined. The formula 
for this calculation is : 

( Total number of leucocytes counted x Degree of dilution ) ~- 
(Cubic contents of visual field x Number of fields examined} = 
Total number of leucocytes per cb. nun. 

For example, in a 1 : 200 blood dilution a total of 30 leucocytes 
are noted in 50 fields, each having a cubic contents of .0125664, 
since they individually include 8 parallel columns of the ruled disc : 

( 30 x 200 ) -r- ( .0125664 x 50 ) = 9,550 leucocytes per cb. mm. 

(U) If the special leucocytometer is used for counting the leu- 
cocytes, a 0.3 per cent, aqueous solution of glacial acetic acid 
must be employed as a diluent, in order to render invisible the 
erythrocytes and at the same time to make the leucocytes appear 
more conspicuously in the field. A 1:10 dilution is made, by 
drawing the blood up the capillary tube of the instrument until 
the mark 1 is reached, and by then adding the diluent until the 
mixture reaches the mark 11. The leucocytes are then counted 
in an area of the counting chamber equal to 800 of the small 
squares (preferably by examining 400 squares in two separate 
drops), and the calculation made according to the method pre- 
viously described. For instance, if in a given case 130 leucocytes 
were counted in 800 squares, the estimate would be made as follows : 

130 x 4,000 x 10 -r- 800 = 6,500 leucocytes per cb. mm. 

The chief objection to this method of leucocyte counting lies 
in the difficulty in distinguishing the cells, owing to the unavoid- 
able presence in the field of masses of granular debris resulting 
from the action of the acetic acid solution upon the erythrocytes. 
For this reason, if for no other, it seems advisable to dispense 



52 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

with the leucocytometer, and to make the count of both red and 
white corpuscles with the eiythrocytometer, in the same drop. 

Cleaning the Pipette. As soon as the count has been finished 
the pipette should be carefully cleaned and dried. Having first 
expelled what remains of the blood dilution, the instrument is 
rinsed out, first with distilled water and then with a mixture of 
equal parts of absolute alcohol and ether, the latter being used to 
remove all traces of the dye, in case either Toisson's or Sherring- 
ton's solution has been employed as a diluent, as well as to dry 
the interior of the tube. The pipette, while it may be filled with 
a fluid by suction, should not be emptied by blowing through it, 
for if this is done a certain amount of moisture from the breath 
unavoidably becomes deposited in its lumen. Its contents may be 
expelled in the form of a fine jet, simply by twisting the rubber suc- 
tion tube into a tight spiral rope, as shown in the illustration (Fig. 
26). When the interior of the instrument is perfectly clean, it 



Fig. 20. 




Expelling contents of erythrocytometer. 

By twisting the rubber suction tube into a tight spiral rope, the fluid in the bore of the pipette may be 
forcibly expelled in a fine jet. 

is dried by forcing through it a current of air, by means of a 
rubber atomizer bulb, or an ordinary bicycle pump, until the glass 
bead no longer clings to the wall of the bulbous expansion, as it 
will as long as the slightest trace of moisture remains. 1 

A new form of hemocytometer has been 
Durham's Hem- recently described by Durham, who has em- 
ocytometer. bodied in this device the principles of the older 
instruments, together with the substitution of a 
self-measuring pipette designed to overcome the sources of error 
which may occur in making blood dilutions with a suction pipette. 
Durham's instrument, which appears to be a valuable improve- 

1 A o.l per cent, solution of pepsin in I per cent, hydrochloric acid is useful for 
removing any bits of clotted blood which may adhere to the caliber of the instrument. 



COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 53 



ment over other forms of blood-counting apparatus, consists of 
the following parts : 

1. Several capillary pipettes , of the Oliver type, each mounted 
in a glass tube, provided with a rubber nipple having a lateral 
perforation. The capacity of the pipettes is of 5 and 10 cubic 
millimeters. 

2. A number of mixing vessels, each consisting of a small glass 
test-tube, graduated for 1 and for 0.5 cubic centimeters of fluid. 
The tubes holding 1 cubic centimeter measure 2-| x ^ inches, 
and those holding 0.5 cubic centimeter, 2-| x J inches. One or 
more glass beads are shaken about in the tube, to mix the blood 
and the diluting fluid. 

3. A number of graduated pipettes , for measuring the diluting 
fluid, of 1 and 0.5 cubic centimeters capacity, marked at 995 and 
990 cubic millimeters, and at 495 and 490 cubic millimeters, 
respectively. Used with the appropriate capillary pipette, dilu- 
tions of 1 in 200, 1 in 100, and 1 in 50 may be obtained. 

4. A counting chamber of the Thoma-Zeiss pattern. 



Fig. 21. 

N 




Cross section of Durham's blood-pipette. 

T, glass tube ; N, rubber nipple ; p, lateral perforation in nipple ; c, cork in which a capillary- 
pipette is fitted. 

Method of Use. Having placed in one of the mixing vessels 
some of the diluting fluid, the quantity of which is measured with 
one of the graduated pipettes according to the dilution desired, the 
capillary pipette is filled with blood, by touching it lightly to the 
blood drop as it flows from the puncture. All traces of blood are 
then removed from the outside of the pipette, the contents of which 
are now expelled into the fluid, contained in the mixing vessel. 
This is accomplished by inserting the pipette into the latter, keep- 
ing its point about half an inch above the level of the diluting fluid, 
and by then rotating it between the thumb and forefinger so that 
the lateral perforation is brought under the pulp of the thumb ; 
the nipple is now squeezed gently, and, continuing the pressure, 
the pipette is rotated back so that the perforation is free again. 
In this manner the blood is forced from the pipette, but is not 
sucked back. The blood remaining in the pipette is now com- 
pletely washed away by thrusting its point into the diluting fluid, 
this at once filling its caliber, by capillarity. Withdrawing the 



54 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

pipette from the fluid, the rotation and pressure of the nipple are 
repeated, the capillary tube being thus rinsed out several times in 
order to remove completely all the blood clinging to its interior. 

The blood and the diluting fluid are now mixed by briskly ro- 
tating the mixing vessel between the opposed hands, so that the 
tumbling about of the glass beads in the vessel may thoroughly 
distribute the cellular elements through the fluid. When the 
mixing is completed, a drop of the fluid is transferred to the 
counting chamber, and the corpuscles counted under the micro- 
scope, in the usual manner. 

Durham's device makes it possible for the unskilled to measure 
accurately the desired volumes of blood and diluting fluid, and 
largely eliminates the errors which are likely to occur in sucking 
up the blood and the diluent with either the Thoma-Zeiss, or 
the Gowers hemocytometer. The ease and thoroughness with 
which the capillary blood pipette may be cleaned is also an ad- 
vantage, this being done by passing through its caliber a piece of 
darning cotton, dry or soaked in ether, by means of a needle. 
Comparative observations made with the Thoma-Zeiss hemocy- 
tometer have shown that the readings of the two instruments are 
practically identical. 

In this form of hemocytometer, the blood and 
Gowers' Hem- the diluting fluid are each measured in a separate 
ocytometer. pipette, and deposited in a small receptacle in 
which they are mixed, a small portion of the mix- 
ture then being placed in a counting chamber and the number of 
corpuscles counted under the microscope. Gowers prefers to use 
as a diluent an aqueous solution of sodium sulphate having a 
specific gravity of 1025, but Toisson's solution, or any of the 
other diluting fluids previously mentioned will prove satisfactory. 
The instrument comprises five working parts, as follows : 

1. A pipette, graduated to hold a volume of 995 cubic milli- 
meters, for measuring the diluting fluid. 

2. A capillary pipette, graduated to hold a volume of 5 cubic 
millimeters, for measuring the blood. 

3. A small glass mixing jar, in which the dilution of the blood 
is made. 

4. A glass stirring rod, for mixing the blood and the diluent 
in the jar. 

5 . A counting chamber, consisting of a glass slide, mounted on 
a brass plate, and containing a cell one-fifth of a millimeter in 
depth, the floor of the cell being divided by cross rulings into 
squares the sides of which measure one-tenth of a millimeter. 
When a cover-glass is fitted over this cell, being retained in po- 



COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 55 



sition by means of a pair of clips attached to either end of the 
brass plate, the cubic contents of the space overlying each square 
measure 1/500 of a cubic millimeter. 

Method of Use. In using the instrument, 995 cubic millimeters 
of the diluting solution are first measured by means of the larger 
pipette, and blown out into the mixing jar. The latter must be 
perfectly clean and absolutely free from moisture before it is used, 
in order to avoid errors in the count. Now, using the capillary 
blood pipette, 5 cubic millimeters of blood are secured from the 
puncture, and immediately added to the diluent contained in the 
jar. The blood and the diluent are then thoroughly mixed, by 
rapidly stirring the solution with the glass rod. The dilution thus 
made is in the proportion of 1 in 200 of blood to diluent. As 
soon as the mixture is completed, a small drop of the solution is 
transferred to the center of the cell in the middle of the counting 
chamber, the small end of the glass rod being used for this pur- 
pose, after which the cover-glass is gently placed in position, and 
the clips adjusted so as to hold it in place. The counting cham- 
ber may then be placed upon the stage of the microscope, and 
the corpuscles overlying the ruled portion of the cell brought 
into focus with a low-power objective. 

It is necessary to use a small drop of the diluted blood, and 
to place it exactly in the center of the block of ruled squares, 
otherwise the fluid may flow towards the walls of the cell, alter- 
ing its volume, and making it necessary to reject the specimen, 
and to prepare a new drop, after thoroughly cleaning and drying 
the cell, and again stirring the blood solution. 

The corpuscles having settled to the bottom of the cell, 
their number in a given number of squares is noted, and the 
final calculation made according to the formula : 

Number of Number of ~ , . , r 

,7 „ J 1 otal number of cor- 

corpuscles x 200 x ^00 — squares = 7 / 

,7 u j puscles per cb. mm. 

counted counted r r 

In counting the erythrocytes at least 20 squares of the count- 
ing chamber should be inspected, in different drops, a procedure 
involving the enumeration of about 1,000 cells, in normal blood. 
Except in high leucocytoses, the number of leucocytes is usually 
estimated indirectly, by determining their ratio to the erythro- 
cytes, and basing their actual number upon this figure. This 
plan (the necessity for which is a serious drawback to the use of 
this instrument) is followed so as to dispense with the tedious 
filling and refilling of the counting chamber, in an endeavor to 
find a sufficient number of leucocytes to serve as a basis for the 



56 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

calculation, should the latter be direct. Ordinarily, not more 
than two of these cells are contained in an area including 20 
squares. Gowers 1 claims that the limit of error with his instru- 
ment is less than 3 per cent. 

After use, the different parts of the instrument are to be thor- 
oughly cleaned and dried, in the manner already described. 

For making rapid numerical estimates of the 
Oliver's Hem- erythrocytes Oliver has designed an instrument 

ocytometer. based upon the following principles : When a 
candle flame is viewed through a flat glass test- 
tube filled with water, a bright transverse line is visible, com- 
posed of densely packed, minute images of the flame produced 
by the longitudinal corrugations of the glass. If for the water a 
mixture of blood and Hayem's solution 2 is substituted, a more or 
less opaque fluid results, so that, in low dilutions, this illuminated 
line is invisible, reappearing only when a definite degree of higher 
dilution is reached, by the gradual addition of the diluent ; when 
this point has been obtained, the line is again detected as a bright, 
delicate streak horizontally crossing the tube. Experiments 
having proved that the development of such a line, by gradual 
dilution of the blood with Hayem's fluid, is an accurate gauge of 
the percentage of erythrocytes in the specimen tested, it remained 
for Oliver to devise a hemocytometer consisting of the following 
essential parts : 

1. A capillary pipette, for measuring the blood. 

2. A glass dropper, one end of which is capped by a rubber 
nipple, the other by a short rubber nozzle which fits over the 
blunt end of the pipette. 

3. A standard graduated tube, in which the blood and the 
diluent are mixed. 

The four walls of the tube are flattened so that it is rectangular 
on cross-section, one wall being provided with an etched scale, 
indicating units from 10 to 120. Each of these divisions is equiv- 
alent to 50,000 erythrocytes, the point marked 100 degrees 
representing the arbitrary normal number, 5,000,000. 

Small-sized wax candles, known as " Christmas candles," are 
to be preferred for the illumination, as they give the small flame 
requisite to obtain a sharply defined line, but the flame from a 
gas-jet turned low may also be used with satisfaction. 

Method of Use. — In making the observation the pipette, which 
has been previously cleaned and dried, is filled with blood in the 
usual manner, and any excess of blood on the outside carefully 

1 Lancet, 1877, v °l- P- 797- 

2 For formula, see page 41 . 



COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 57 



removed. The rubber nozzle of the dropper, filled with Hayem's 
fluid, is then slipped over the blunt end of the pipette, and the blood 
washed out into the graduated tube by squeezing the nipple. 
This preliminary dilution is continued until the column in the 
tube rises to within 10 or 1 5 degrees below the figure for the 
hemoglobin percentage of the same blood, this having been pre- 
viously determined. For instance, if the hemoglobin percentage 
was found to be 70, the diluting fluid is added in large quan- 
tities until the mixture in the tube reaches to about the mark 60, 
after which it is added more cautiously, and in smaller quantities 
at a time, careful search for the bright line being made after each 
addition. In cases of chlorosis and of pernicious anemia, in 
which parallelism between the hemoglobin and corpuscular loss 
is lacking, it is, of course, impossible to depend upon the hemo- 
globin percentage as an index to the amount of diluent required, 
so that in instances of this kind the line must be developed more 
slowly, by making a smaller primary dilution, and by adding the 
requisite volume of liquid more deliberately. 

After the first dropperful of diluent has been added to the con- 
tents of the tube, the latter are mixed by inverting the tube a 
number of times with 
the thumb held over 
its mouth, the precau- 
tion being taken also 
to remove the thumb 
by drawing it over the 
mouth of the tube, in 
order to restore to its 
contents any liquid 
which may have ad- 
hered to the skin. The 
tube should be thus 
inverted after each ad- 
dition of the diluting 
fluid. 

The steps of the ob- 
servation succeeding 
the measuring; of the , 

° . lary pipette into the tube containing Hayem s solution. 

blood and its primary 

dilution are to be made in a dark-room, free from cross lights, 
the candle being placed about ten feet distant from the observer. 
In order to shut out the diffused light of the candle, the tube 
should be held vertically in the concavity formed between the 
thumb and forefinger, the tube being kept close to the eye while 



Fig. 22. 




Method of using Oliver's hemocytometer. 
Showing manner in which the blood is washed from the capil- 



58 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

searching for the bright line. Oliver states that the earliest 
indications of this line are obtained by turning the tube on its 
axis, when it will become visible at the sides of the tube. 

It is claimed that tests made with this instrument are accurate 
within one per cent., and that in many cases it may be used as a 
substitute for the more laborious method of counting the cor- 
puscles under the microscope. It is obvious, however, that, apart 
from the " personal equation," the serious drawback to this test 
is its failure to indicate the number of leucocytes, this fact alone 
being sufficient to curtail its use for routine clinical work. It is 
also apparent that in cases of marked leucocytosis and of leuke- 
mia the optical principles of the test must necessarily fail because 
of the enormous number of leucocytes in the blood. Further- 
more, it is reasonable to infer that the instrument will give false 
results with blood in which conspicuous deformities of the eryth- 
rocytes exist, for the reason that the standard tube is corrected 
for normally shaped corpuscles, so that blood composed largely 
of microcytes, or megalocytes, or poikilocytes will give different 
readings from blood in which the cells are of unaltered biconcave 
shape and of normal size. 

IV. EXAMINATION OF THE STAINED SPECIMEN. 

The microscopical study of the dried and 
Objects of stained blood-film, which should supplement the 
Staining. methods of investigation just described, is for 
many reasons the most important step in the 
clinical examination of the blood. By means of this method 
of "color analysis" it is possible to differentiate easily and with 
absolute certainty the various forms of leucocytes and, by differ- 
ential counting, to calculate the relative percentages of each 
variety of these cells ; to distinguish the several structural de- 
generative changes affecting chiefly the erythrocytes, and to a 
less extent the leucocytes ; and to recognize and classify accord- 
ing to their histological character the nucleated forms of the eryth- 
rocytes. To sum up, in the words of Ehrlich, 1 to whom we 
owe this rational means of investigation : " Everything that is 
to be seen in the fresh specimens — apart from the quite unim- 
portant rouleaux formation and ameboid movements — can be 
seen equally well, and indeed much better, in a stained prepara- 
tion ; and there are several important details which are only made 
visible in the latter, and never in wet preparations." 

1 Ehrlich and Lazarus: "Die Anaemie," Wien, 1900. (Nothnagel's "Spec. 
Path. u. Therap.," vol. viii., n. 2.) 



EXAMINATION OF THE STAINED SPECIMEN. 



59 



According to the classification introduced 
The Aniline twenty years ago by Ehrlich, 1 the aniline dyes 
Dyes. are divided into three different groups : acid, 
basic, and neutral. Acid dyes, or compounds in 
which the coloring principle acts or exists as an acid, possess a 
special affinity for cell protoplasm, and, therefore, are generally 
employed as plasma stains ; in hematological work acid fuchsin, 
eosin, and orange G are the principal dyes used for this purpose. 
Basic dyes, or compounds in which the coloring principle exists 
chemically as a base in combination with a colorless acid, are 
especially useful as nuclear stains, since they exhibit a special 
affinity for chromatin structures ; members of this group of 
dyes commonly used in blood staining are methylene-blue, tol- 
uidin-blue, methyl-green, methyl-violet, thionin, and hema- 
toxylin. Neutral dyes are the coloring principles which re- 
sult from the mixture of solutions of an acid and a basic dye ; 
they are used for the demonstration of the so-called neutro- 
philic granules of the leucocytes, for which they show a selective 
affinity. 

For the preparation of the dried blood-films it 
Preparing is advisable to have at hand at least half a dozen 
the Films, perfectly clean, polished cover-glasses, which 
may be arranged in pairs on a sheet of white 
paper within convenient reach of the examiner. After having 
wiped away the blood which immediately follows the puncture, a 
minute portion of the next 
drop is collected, by lightly 
touching the center of one of 
the cover-glasses to its sum- 
mit, care being taken to avoid 
bringing the polished surface 
of the glass in contact with 
the skin of the patient's finger. 
The charged cover-glass is 
then at once dropped, blood 
side downward, upon the sur- 
face of the second glass (Fig. 23), with the result that the 
blood quickly spreads out in a thin film between the two, and ex- 
tends to their peripheries, provided that the proper quantity of blood 
has been used. (Fig. 24.) As soon as the film has reached the 
margins of both cover-glasses, they are rapidly drawn apart in a 
horizontal direction, so that the surface of each, when thus 
separated, is covered with a thin layer of blood (Fig. 25), which 

^eitschr. f. klin. Med., 1880, vol. i., p. 555. 



Fig. 




1. Superimposing the charged cover-glass. 



60 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 



should be rapidly dried, either by blowing briskly upon its sur- 
face, or by holding the glass for a few seconds high over the 
flame of an alcohol lamp. If care is taken to use but a very 

small drop of blood, to avoid 
FlG - 2 4- pressure in opposing the sur- 

faces of the two cover-glasses, 
and to separate them in their 
true horizontal planes, the 
films will consist of a single 
layer of corpuscles, most of 
which will be sufficiently iso- 
lated to allow the study of 
their individual morphology 
2 . drawing apart the cover-glasses. and other characteristics. The 

beginner should persistently 
practice the technique of film making until he is able to obtain 
a satisfactory percentage of good specimens from every batch 
of spreads. Thick, uneven spreads, in which the corpuscles are 
heaped up and glued together in dense masses, are practically 
of no value for microscopical study ; such specimens should 
therefore be rejected at 

once, since it is time wasted FlG - 2 5- 

to attempt satisfactorily to 
stain them. 

The films, after having 
been dried, may be placed 
in a pill box, and labelled, 
to await fixation and stain- 
ing at the examiner s con- 3 Xhe cover-glasses after separation. 
venience. Dried specimens 

will keep for an indefinite period, if not exposed to dust or to 
moisture. Unfixed cover-glass specimens of leukemic blood 
have been stained by the writer, with perfect results, more than 
three years after they were spread. 

Many histologists recommend the use of special forceps for hold- 
ing the cover-glasses while making the spreads, claiming thus to 
avoid the injurious effects upon the blood corpuscles which may 
be caused by the moisture of the fingers, if the latter come in 
contact with the films. The careful worker need have no fear on 
this score, for if the covers are held in the manner shown in the 
illustrations this accident will not occur. A pair of light thumb 
forceps is useful for picking up the cover-glasses from a flat sur- 
face, but the employment of special spreading forceps is quite 
superfluous. 





EXAMINATION OF THE STAINED SPECIMEN. 6 1 

As a step preliminary to staining, the albumi- 
Fixation noid principles of the blood must be fixed, by ex- 
Methods. posing the dried film either to a high degree of 
dry heat, or to various chemical hardening agents, 
the choice between these two methods being determined by the 
character of the staining solution to be used subsequently. 

Heat Fixation. This method may be employed with any of 
the stains described in the following pages ; it must be used with 
Ehrlich's triple stain, in preference to fixation by chemicals, in 
order to obtain crisp, clean-cut pictures. 

The author is accustomed to use an oven, such as is illustrated 
below (Fig. 26), consisting of a copper box with a heavy bottom, 
and hinged cover, mounted on an 
ordinary iron burette stand, by Fig. 26. 

means of a thumb-screw. A small 
" baby" Bunsen lamp placed under- 
neath the box furnishes the requi- 
site degree of heat, the temperature 
being indicated by a thermometer 
mounted at one end, and resting 
upon the floor of the oven. By 
sliding the latter up and down the 
vertical rod to which it is attached, 
the desired degree of temperature 
may be obtained at will. The blood- 
films are enclosed in the copper 
box, and the latter fixed at a point 
eight inches above the summit of 
the burner, after which the gas is 
lighted and allowed to burn until 
the temperature, as indicated by the oven for fixing blood-films. 
thermometer, has gradually crept 

up to 160 0 C. As soon as this degree of heat has been reached, 
the gas is extinguished, the cover of the oven thrown back, and, 
after the temperature has fallen to 30 0 C, the films removed, 
being now thoroughly fixed, and ready for staining. Fifteen 
minutes suffice for the whole operation, from the time the gas is 
lighted, until the films have been removed and cooled, for staining. 

A less satisfactory method of heat fixation is by the use of a 
copper plate upon which the films are kept at a temperature of 
from 100 0 to no° C, for from one-half to one hour. The ap- 
paratus used for this purpose consists of a rectangular plate of 
sheet copper, about fifteen inches long, by four inches wide, by 
one-sixth of an inch thick. An alcohol or a Bunsen lamp bums 




62 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

under one end of the plate, which is elevated about six inches 
above the flame, by four metal legs. After having heated the 
plate for ten or fifteen minutes, until a relatively constant tem- 
perature becomes established, water is dropped upon its surface, 
beginning with the end farthest from the flame, until a point is 
reached at which the water boils. This part of the plate is con- 
sidered to have a temperature of ioo° C, and at this point the 
blood-films are placed, " spread" side downward, and heated for 
the required time. No one with much blood staining to do will 
choose this method of prolonged heating at a relatively low, ap- 
proximate temperature in preference to brief heating at a high, 
definite temperature in an oven. The use of the latter, aside 
from its convenience as a time-saver, insures constant and cer- 
tain results, for over- and underheating of the blood-film may 
be avoided, since the degree of heat is exactly indicated and easily 
controllable. In triple stained specimens the blood cells are much 
more brilliantly colored and sharply differentiated when the films 
are fixed at a temperature of 160 0 C, than at a lower degree. 

Should nothing but a Bunsen or an alcohol lamp be available, 
the cover-glass film, held with a pair of forceps, may be fixed by 
passing it rapidly through the flame thirty or forty times and then 
holding it twelve or fifteen inches above the flame for a minute 
or so. This makeshift method, which is often sufficient for a hur- 
ried clinical examination, usually gives fair, and sometimes very 
good, results, but the fixation is generally uneven, and the speci- 
men is frequently scorched in some places and underfixed in 
others. 

Chemical Fixation. Immersion of the dried films in ether, in 
absolute alcohol, or in a mixture of equal parts of the two (Niki- 
fo raff's method) gives satisfactory results with specimens stained 
by any of the single basic dyes, or with the simpler double stains, 
such as eosin and methylene-blue or hematoxylin. The time of 
fixation varies from five to fifteen minutes with any of these agents, 
the specimen then being dried without using heat, and stained 
without previously washing. If time is an object, the specimens 
may be boiled for one minute in a test-tube containing absolute 
alcohol, as advised by Ehrlich. 1 Some workers employ one 
minute's fixation by a one per cent, alcoholic solution of forma- 
lin (Benario's method), while others prefer to expose the films to 
the vapors of this chemical for the same length of time. Solley 2 
has recently suggested that the film be flooded with a two per cent. 

1 Loc. cit. 

2 Med. and Surg. Reports of the Presbyterian Hospital, N. Y., 1900, vol. iv., p. 
169. 



EXAMINATION OF THE STAINED SPECIMEN. 



63 



aqueous solution of chromic acid, which is washed off after exactly 
thirty seconds, the specimen being then stained, while still wet ; 
he recommends this procedure as a substitute for heat in fixing 
specimens for triple staining, but the method, while fairly good, 
cannot be regarded as entirely satisfactory. In the author's hands 
a two per cent, aqueous solution of osmic acid has been found to 
be the best substitute for heat fixation. 

In hematological, as in other histological work 
Methods of the choice of a staining method is determined by 

Staining. the character of the investigation to be undertaken. 

For general clinical purposes it is advantageous 
habitually to employ some routine method by means of which 
the greatest possible number of elements may be demonstrated 
in a single blood-film, this procedure being known as panoptic 
staining. Thus, by using a solution containing several of the 
aniline dyes the stroma of the erythrocytes, the cell-granules, the 
cell-nuclei, and the various blood parasites may be simultaneously 
stained each in a characteristic manner, owing to the selective 
affinity displayed by the different coloring principles of the mix- 
ture towards these several histological elements. The most useful 
solutions which have been devised for this purpose are the triacid 
mixture of Ehrlich, 1 which has long served as the standard stain 
for hematological investigation, and the methylene-blue eosinate 
solution suggested by Jenner. 2 Practically all the information 
that it is possible to derive from the study of the stained dry 
blood-film may be obtained with the aid of these two solutions. 

Combinations of an acid and a basic dye, such as eosin and 
methylene-blue, eosin and hematoxylin, and orange and hema- 
toxylin are used by many investigators, chiefly for the purpose 
of staining the cell-stroma and the nuclear structures ; but, as a 
general rule, such mixtures are not adapted for clinical work, 
since with none of them is it possible to differentiate the neutro- 
phil granules. Solutions of a single dye are but seldom used 
except for the demonstration of special elements, such, for in- 
stance, as the staining of the malarial parasite by thionin, the 
mast-cells by dahlia, and certain bacteria by the basic dyes, such 
as methylene-blue and gentian-violet. Since by this method of 
staining only the particular elements toward which the dye reacts 
are differentiated, the employment of single stains is inadequate 
for the study of the general morphology of the blood cells. 

The following formulae will be found sufficient for all purposes 
of clinical investigation : 

1 Loc. cit. 

2 Lancet, 1899, vol. i., p. 370. 



64 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

Ehrlich's Triacid Stain. This valuable triple stain, con- 
taining one basic and two acid dyes (methyl-green, orange G, 
and acid fuchsin), is peculiar in that a chemical combination is 
formed by its acid and basic components which may be regarded 
as a neutral coloring principle, serving the purpose of selectively 
staining the so-called neutrophile elements for which the primary 
components of the mixture have no affinity. With this stain his- 
tological structures having an affinity for the acid dyes are 
stained the color of one of its acid constituents, basic structures 
the color of its basic dye, and structures having an equal affinity 
for acid and basic dyes the color of the neutral compound. 

Saturated aqueous solutions of the three dyes are first pre- 
pared, and allowed to stand for several days until they have 
become thoroughly cleared. It is essential that the aniline dyes 
used for making these " stock" solutions should be chemically 
pure, to ensure which the products of Grubler, or of the Berlin 
Aniline Dye Company should invariably be chosen. From these 
saturated solutions the following mixture is made : 



Acid fuchsin solution 6- 7 cc. 

Orange G solution I 3~i4 cc. 

Distilled water 15 cc. 

Absolute alcohol 15 cc. 

Mix the above thoroughly, and add, drop by drop, 
with continuous agitation, in the following order : 

Methyl-green solution 12.5 cc. 

Absolute alcohol 10 cc. 

Glycerine 10 cc. 



The mixture should under no circumstance be filtered, but al- 
lowed to stand for about twenty-four hours in order that a slight 
precipitate may form. As soon as this occurs the stain is ready 
for use, the necessary quantity being pipetted from the super- 
natant fluid without disturbing the precipitate. 

Technique of Staining. The heat-fixed film, held preferably 
with a pair of Stewart's staining forceps, is flooded with the stain, 
which is washed off in running water after the lapse of from five 
to eight minutes, the specimen then being dried by gentle heat, 
and mounted in xylol balsam, or in cedar-oil. 

In the specimen thus prepared the stroma of the erythrocytes is 
stained orange, the nuclei of the leucocytes greenish-blue, the neu- 
trophile granules violet or lavender, and the eosinophile granules 
copper red. The nuclei of the erythroblasts react with varying 
degrees of intensity toward the basic component of the mixture, 
those of the normoblasts staining deep purple or black, and those 
of the megaloblasts pale green or greenish-blue. The basophile 



EXAMINATION OF THE STAINED SPECIMEN. 



65 



granules remain unstained, appearing as dull white, coarse, 
stippled areas in the cell-protoplasm — " negative staining." In 
order to stain these granules, as well as the basic protoplasm of 
the lymphocytes, Hewes 1 suggests that the triple stained film, 
after having been washed, be subjected for from one-half second 
to ten seconds to Loffler's 2 methylene-blue solution, after which it 
is again washed, and mounted as above directed. This modifica- 
tion is of undoubted value, chiefly because it usually enables one 
to differentiate the larger forms of lymphocytes from the large 
mononuclear leucocytes. Malarial parasites, and bacteria are 
also distinctly stained by this method. 

Unsatisfactory results with the triple stain, provided that the 
latter is properly made, can almost always be attributed to faulty 
fixation. As already remarked, heat is the only method of fixa- 
tion which will insure faultless differentiation in the specimen 
stained with this mixture. The perfect specimen is of a deep, 
rich orange tint to the naked eye ; if underheated, the film reacts 
too strongly toward the acid fuchsin of the mixture, and, conse- 
quently, is the color of this dye ; if overheated, the plasma 
stain, orange G, is but feebly displayed, so that the color of the 
film is pale lemon yellow. 3 

Jenner's Stain. This solution, made by dissolving in methyl 
alcohol the neutral precipitate obtained by the addition of methyl- 
ene-blue to eosin, is especially valuable in the study of the lym- 
phocytes, and the mast-cells. It should be made according to 
the following somewhat complicated formula : 

(#) Eosin (aqueous) 1.25 grm. 

Distilled water 100 cc. 

(£) Methylene-blue (medicinal) 1.0 grm. 

Distilled water 100 cc. 

Equal parts of these two solutions, "a" and "b," are mixed 
together, stirred thoroughly with a glass rod, and set aside for 
twenty-four hours, so that complete precipitation may occur. In 
making this mixture, the methylene-blue solution should be added 
to the eosin solution (never vice-versa) in small quantities at a 
time, the fluid being constantly stirred during the addition. A 
burette with the stop-cock regulated so as to deliver the former 
dye-solution, drop by drop, in rapid succession, will prove useful 
to insure the slow admixture of the two fluids. The precipitate 

1 Boston Med. and Surg. Journ., 1899, vol. cxli., p. 39. 

2 Saturated alcoholic solution of methylene-blue, 30 cc; 1-10,000 aqueous solution 
of potassium hydrate, 100 cc. 

3 A reliable triacid stain, made according to Ehrlich's formula, is sold by Messrs. 
Shinn and Baer, Philadelphia. 

5 



66 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

is collected by filtration, dried in an incubator, at a temperature 
of 55 0 C, and powdered in a mortar. The powder should then 
be washed, by shaking it up with distilled water, and filtering, 
after which it is allowed to dry in the air, and kept in a tightly 
corked bottle. The mixture used for staining is made by dis- 
solving 0.5 grm. of this powder in 100 cc. of pure methyl alcohol 
(Merck), and filtering. 

Technique of Staining. Owing to the methyl alcohol which 
it contains, Jenner's solution fixes and stains the blood-film 
simultaneously, so that preliminary fixation may be omitted. 
The unfixed specimen is stained for from three to five minutes, 
washed in water until the film is of a rose-red color, dried in air, 
and mounted in the usual manner. Since the solution is of an 
exceedingly volatile character, as much of it should be used as 
can be placed on the cover-glass without spilling ; if this is not 
done, the specimen may be ruined, owing to the rapid evapora- 
tion of the stain around the margins of the cover-glass. 

Jenner's stain gives the following results : erythrocytes, terra 
cotta ; nuclei of the leucocytes, pale sea-green ; neutrophile 
granules, pate pink ; eosinophile granules, deep pink ; fine baso- 
phile granules, deep blue ; and coarse, mast-cell granules, deep 
royal purple. The nuclei of the erythroblasts, and the blood 
parasites stain various shades of bluish-green, and the pseudo- 
granular protoplasm of the lymphocytes, blue. 

The chief defect in Jenner's stain is the occasional presence of 
a coarse, granular precipitate which mars the appearance of an 
otherwise perfect specimen. If, however, the precaution is ob- 
served always to filter the stain before use, and to dry the film 
in air — not by holding it over a Bunsen flame — this accident may 
generally be avoided. Aside from its obvious value as a panop- 
tic staining fluid, this solution will often prove of great convenience 
for the reason that it does not require special fixation of the blood- 
film. 

Prince's Stain. This mixture, which consists of an aqueous 
solution of one basic and two acid dyes, is an excellent stain for 
the differentiation of both nuclei and granules, and may be em- 
ployed as a fair substitute for either of the two preceding solutions. 
It should be made in this manner : 

Saturated aqueous solution of toluidin-blue 24 cc. 

Saturated aqueous solution of acid fuchsin 1 cc. 

2 per cent, aqueous solution of eosin 2 cc. 

These solutions are mixed in the order named, and shaken 
briskly for several minutes, so as to secure complete precipitation 



EXAMINATION OF THE STAINED SPECIMEN. 



6 7 



of the basic toluidin-blue by the acid dyes. The solution, which 
should not be filtered, is ready for use as soon as made. Only 
the supernatant fluid should be employed, care being taken not 
to disturb the sediment. 

Technique of Staining. If a newly made solution is used, the 
films are stained for from one-half to one minute, after which they 
are rinsed in water, dried in air, and mounted ; but if the solution 
has stood for several weeks, its basic constituent becomes less 
active, so that the specimen requires to be stained for from five to 
ten minutes. Either chemical or heat fixation of the blood-film 
may be used with this stain, both methods giving equally sharp dif- 
ferentiation. Prince's solution colors the erythrocytes rose-red, the 
nuclei of the leucocytes and erythroblasts blue, the neutrophile 
granules pink, the eosinophile granules maroon, and the fine and 
coarse basophile granules blue. Blood parasites are also stained 
the color of the basic dye. 

Double Staining with Eosin and Methylene-blue. Crisp, 
clear pictures of nuclear and stroma structures, of the ma- 
larial parasites, and of the basophile granules may be obtained 
be the use of these two dyes, and to investigations of this nature 
should this staining method be restricted. It is impossible, for 
example, accurately to distinguish a large lymphocyte from a 
myelocyte in a specimen stained in this manner, so that for differ- 
ential counting a more elaborate stain is essential. In films stained 
by this method the stroma of the erythrocytes and the eosinophile 
granules react toward the acid dye, staining the color of eosin ; 
while the nuclei of the leucocytes and erythrocytes, the basophile 
granules, and all blood parasites show an affinity for the basic 
dye, being colored various shades of blue. The protoplasm of 
the polynuclear neutrophils is either colorless or tinged a deli- 
cate pink, the granules of these cells remaining unstained. 

The author has always found the following simple formula de- 
pendable : 

Eosin (aqueous), to which sufficient water has 



Saturated aqueous solution of methylene-blue.. 96.0 cc. 

Technique of Staining. Films are fixed by immersion for ten 
minutes in. absolute alcohol, or in equal parts of absolute alcohol- 
and ether. The cover-glass is flooded with the stain, gently 
heated for one minute over a Bunsen flame, allowed to stain 
without heat for two or three minutes longer, and then thoroughly 
washed in running water, dried in air, and mounted. 



been added for solution 
Absolute alcohol 



0.5 grm. 
0.5 cc. 



68 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

Another method of staining with eosin and methylene-blue, 
slower than the above, but as a rule giving sharper differentiation, 
is to stain without heat for five minutes with a o. 5 per cent, solu- 
tion of eosin in absolute alcohol to which an equal quantity of 
water is added. Then, after having washed off the eosin solution 
and dried the film in air, the specimen is counterstained for one 
minute or less with a saturated aqueous solution of methylene- 
blue, after which it is rinsed again in water, dried in air, and 
mounted. 

Among the many other methods of staining with eosin and 
methylene-blue, those suggested by Chenzinsky, 1 by Plehn, 2 and 
by Holmes 3 will be found the most useful. 

Double Staining with Eosin and Hematoxylin. By the em- 
ployment of these two dyes the erythrocytes and the eosinophile 
granules are stained the color of eosin, and all nuclei and parasites, 
the color of hematoxylin. This method, which is decidedly in- 
ferior to staining with the eosin and methylene-blue mixtures just 
described, is useful for little else than the study of nuclear struc- 
tures. It should not be used for differential counting, since in 
films stained in this manner the neutrophile granules are invisible. 
Ehrlich 4 recommends this formula : 



Eosin (cryst. ).. 0.5 grm. 

Hematoxylin 2.0 grm. 

Absolute alcohol 100.0 cc. 

Distilled water 100.0 cc. 

Glycerine 100.0 cc. 

Glacial acetic acid 10. o cc. 

Alum in excess. 



This mixture must " age " for several weeks before it 
can be used for staining. 

Technique of Stai?iing. Specimens, fixed either chemically or 
by heat, are stained for from one-half hour to two hours, thor- 
oughly washed in water, dried and mounted. In order to obtain 
the best results, it is advisable to filter the solution before using, 
and to wash the films very thoroughly after staining. 

If time is an object, the following rapid method may be substi- 
tuted for the above : The film is first stained for about five 
minutes with a 0.5 per cent, solution of aqueous eosin in fifty per 
cent. alcohol, washed, and dried in air ; it is then counterstained 

1 Zeitschr. f. wiss. Mik., 1894, vol. xi., p. 260. 

2 " Aetiologische und klinische Malaria Studien," Berlin, 1890. 
3 Journ. Am. Med. Asso., 1898, vol. xxx., p. 303. 

4 Loc. cit. 



EXAMINATION OF THE STAINED SPECIMEN. 



6 9 



for about one-half minute with Delafield's hematoxylin, 1 washed 
for a second time, and mounted in the usual manner. 

Staining with Thionin. Thionin ( also known as the " violet 
of Hoyer," and the "violet of Lauth " ) is an excellent stain 
for blood parasites in general, being especially useful for the 
demonstration of the malarial parasites and the filarial embryos. 
Thionin should not be used as a stain for films in which the gen- 
eral morphology of the blood cells is to be studied, since the baso- 
phile granules and the nuclei are the only histological elements 
for which it displays any decided affinity. Structures reacting 
toward the dye are stained violet of varying degrees of intensity. 
The following recipe, suggested by Futcher and Lazear, 2 will 
prove satisfactory : — 

Thionin 0.3 grm. 

Absolute alcohol 10.0 cc. 

1 per cent, solution of carbolic 

acid q. s. ad 100.0 cc. 

Technique of Staining. Films which have been fixed either 
chemically or by heat are stained in the above solution for from 
one to three minutes, being then washed in water, dried, and 
mounted as usual. The best results are obtained by using the 
French thionin, made by Cogit et Cie, of Paris. 

Staining with Polychrome Methylene-blue. Goldhorn's 
solution of methylene-blue and lithium carbonate affords a 
rapidly acting stain, superior to all others for the demon- 
stration of the finer structure of the malarial parasite in every 
phase of its development. In addition to giving crisp, clear-cut 
pictures of the chromatin of this organism, the solution also 
brings out distinctly the granular degeneration of the erythro- 
cytes, the nuclear characteristics of the erythroblasts and leuco- 
cytes, the basophile granules, and all ordinary bacteria. 

Technique of Staining. The films are fixed for fifteen seconds 
in methyl alcohol, rinsed in water, and then stained, unheated, 
for from one to two minutes, after which they are thoroughly 

1 This solution is made by first adding 4 grms. of hematoxylin crystals, dissolved 
in 25 cc. of alcohol, to 400 cc. of a saturated aqueous solution of ammonia-alum. 
The mixture is left exposed to the sunlight and air in an uncorked bottle for four 
days, at the end of which time it is filtered, and mixed with 100 cc. each of methyl 
alcohol and glycerine. This solution is allowed to stand until it becomes dark- 
colored, when it is filtered, and placed in a tightly corked bottle, to " age" for at 
least two months before it can be used successfully for staining. Owing to the com- 
plicated manner in which Delafield' s hematoxylin must be prepared, it is usually pref- 
erable to purchase it ready-made, from a dealer in microscopical supplies, Griibler' s 
make being entirely reliable. 

2 Johns Hopkins Hosp. Bull., 1899, vol. x., p. 70. 



JO EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

washed in running water, dried without the use of heat, and 
mounted in balsam. Preliminary staining for ten or fifteen sec- 
onds with a o. i per cent, aqueous solution of eosin, followed by 
washing, gives a picture in which the contrast between the plasma 
and the basic elements of the cells is clearly differentiated. Poly- 
chrome methylene-blue, prepared according to Goldhorn's for- 
mula, 1 is sold by dealers in laboratory supplies, or it may be 
made in this manner : — 

Two grammes of methylene-blue are dissolved in 300 cubic 
centimeters of warm water and 4 grammes of lithium carbonate 
are added, with constant agitation. The mixture is poured into 
an uncovered porcelain capsule, which is heated over a shallow 
water-bath for ten or fifteen minutes, being frequently stirred with 
a glass rod. After removal from the water-bath, the fluid is bot- 
tled, without filtering, and set aside for several days, after which 
its reaction is corrected by the cautious addition of a 5 per cent, 
acetic acid solution until the dye is but very faintly alkaline. 
Should the solution become too alkaline after having been kept 
for some time, its reaction may be corrected by adding a small 
quantity of acetic acid, as in the preparation of the original 
mixture. 

A differential count of the leucocytes consists in 
Differential determining, by microscopical examination of the 
Counting, stained specimen, the relative percentages of the 
different varieties of these cells, the estimate be- 
ing based upon a count of several hundred cells, which are clas- 
sified according to the several forms described in a following 
section. (Section IV.) This procedure, by means of which 
qualitative changes affecting the leucocytes may be detected, is 
obviously a most important step in every blood examination, and 
one which should not be regarded as of secondary importance to 
the numerical estimate with the hemocytometer. 

The technique of differential counting consists simply in exam- 
ining successive microscopical fields until at least five hundred 
leucocytes have been counted, the cells in each field of vision 
being identified as they appear, and jotted down on a piece of 
paper by the observer under their appropriate class. As soon as 
the requisite number of cells has been counted, the percentages 
of the different forms are calculated, to express the final result. 
For the examination a one-twelfth inch oil-immersion objective is 
practically indispensable, for to any but the skilled worker it is 
difficult, if not sometimes impossible, to distinguish the various 

1 Johns Hopkins Hosp. Bull., 1899, vol. x., p. 70. Also, N. Y. Univ. Bull, of 
Med. Sc., 1901, vol. i., p. 57. 



COUNTING THE BLOOD PLAQUES. 



71 



forms of leucocytes with a lower magnification than this lens 
provides. In order to be certain that each field is taken in ac- 
curate succession to its neighbor, the slide should be moved 
across the visual field by the aid of a mechanical stage ; systematic 
examination of any given area of the specimen is well nigh an 
impossibility, if the slide is simply laid on, or clipped to, the stage 
of the microscope, and pushed across it with the fingers alone. 

If nucleated erythrocytes are found in the specimen, it is 
equally important to include them also in the differential count, 
classifying them in two histological divisions, normoblasts and 
megaloblasts. In calculating the number of these cells, it is 
obviously impossible to employ any direct method, so that the 
estimate must of necessity be more or less approximate, since it 
is based upon the ratio of erythroblasts to a given number of 
leucocytes. Having first counted the latter with the hemocytom- 
eter, the number of nucleated erythrocytes is noted in an area 
of the stained specimen in which a fixed number of leucocytes 
is contained, and having ascertained these data, the estimate is 
made according to the formula : 

Number of erythroblasts Number of leucocytes Number of 

counted in the stained film X per cb. mm. erythro- 
Number of leucocytes ~~ blasts per 

counted in the stained film cb. mm. 

For example, in a case of pernicious anemia in which the leu- 
cocytes number 4,000 per cubic millimeter, and a total of 35 
erythroblasts are noted while counting 1,000 leucocytes in the 
stained film, the calculation is as follows : 

35 x 4,000 -5- 1,000 =140 erythroblasts per cb. mm. 

Whenever erythroblasts are found, it is important to determine 
their number to the cubic millimeter of blood, and should nor- 
moblasts and megaloblasts both occur, to estimate the ratio be- 
tween these two types of cells. 



V. COUNTING THE BLOOD-PLAQUES. 

Determann's method 1 of indirectly estimating the number of 
plaques to the cubic millimeter of blood is both simple and ac- 
curate. It consists, briefly, in first determining the ratio of these 
elements to the erythrocytes, which are then counted, to furnish 
the basis for the final calculation. 



J Deut. Archiv. f. klin. Med., 1899, vol. lxi., p. 365. 



72 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

In obtaining the blood, a drop of the diluting fluid is placed 
upon the patient's finger and the puncture made through it, in 
order that the blood, as it flows from the puncture, will instantly 
mix with the diluent without coming in contact with the air. 
The blood and diluent are then thoroughly mixed for a few mo- 
ments by the aid of a cover-glass, after which a small portion of 
the mixture is transferred to a Thoma-Zeiss counting chamber, 
and the ratio of plaques to erythrocytes determined under the 
microscope. In the healthy adult this ratio, according to Deter- 
mann, ranges from i to 18 to i to 30, averaging about 1 to 22. 
With another drop of blood the erythrocyte count is then made 
by the usual method, and the actual number of plaques to the 
cubic millimeter of undiluted blood calculated from the figure 
thus obtained. For example, in a given specimen of blood in 
which the ratio of plaques to erythrocytes is found to be 1 to 25, 
the count of the latter cells being 5,000,000, the actual number 
of plaques is therefore 200,000 per cubic millimeter. 

The diluents for which Determann expresses a preference are 
either a 9 per cent, aqueous solution of sodium chloride to which 
a little methyl-violet has been added, or an aqueous solution con- 
taining one per cent, of sodium chloride and 5 per cent, of 
potassium bichromate ; but any of the diluting fluids already 
mentioned are suitable for the purpose. 



VI. ESTIMATION OF THE RELATIVE VOLUMES OF 
CORPUSCLES AND PLASMA. 

The use of centrifugal force for the purpose of determining the 
relative volumes of blood corpuscles and plasma was first applied 
in a practical manner by Hedin, 1 who embodied the earlier ideas 
of Blix in an instrument known as the hematocrit. More re- 
cently Daland, 2 by improving the mechanical construction of the 
original instrument and by simplifying the technique of using it, 
has made centrifugalization of the blood a method of investigation 
adapted to general clinical work. By the use of the hematocrit 
a pair of capillary glass tubes filled with undiluted blood are ro- 
tated in their horizontal axes at a high rate of speed until, as the 
result of the centrifugal force thus applied, the corpuscular and 
liquid portions of the blood become separated, the former being 
distinguishable in the lumen of the tube as a column the length 

1 Skandinavisch. Arch. f. Physiol., 1890, vol. ii., p. 134. 

2 University Med. Magazine, 1891, vol. iv., p. 85. Also, Edwards' supplement 
to Keating's " Cyclopedia of the Diseases of Children," Philadelphia, 1899 ; vol. v., 
P- 537- 



ESTIMATION OF CORPUSCLES AND PLASMA. 



75 



of which is dependent upon the volume which the corpuscles con- 
stitute in relation to the rest of the blood mass. 

This instrument (Fig. 27) is composed of a 
D Aland's set of cog-wheels enclosed in a metal box and 
Hematocrit, geared in such a manner as to cause ten thou- 
sand revolutions per minute of a vertical spindle, 
by turning a handle at a definite, uniform rate of speed. A 
metal frame, which may be securely fastened to the spindle 
by a modified bayonet-lock, carries a pair 
of capillar}* glass tubes, each of which Fig. 27. 

fits into two cup-like, rubber-lined de- 
pressions, and is adjusted and held in 
place by a spring. Each tube measures 
fifty millimeters in length with a lumen 
of half-a-millimeter, and has engraved 
upon its outer surface a scale represent- 
ing one hundred equal divisions, the 
glass immediately above the scale being 
moulded so as to form a lens-front, to 
magnify the column of blood and to 
facilitate the reading of the divisions. 
A bit of rubber tubing, fitted with a 
mouth piece, is used for filling the capil- 
lary tube, in the same manner in which 
the blood is measured with the hemocy- 
tometer. While in use the instrument 
is securely attached to the projecting 
edge of a table or shelf, by means of a 
clamp operated by a thumb-screw. 

Method of Use. Having cleaned and punctured the pa- 
tient's finger in the usual manner, the beveled end of one of 
the capillary tubes is immersed in the drop of blood, which 
is sucked up the lumen of the tube until it is exactly filled. 
The forefinger, smeared with a little vaseline, is then applied 
to the beveled end of the tube, while the rubber suction tube 
is carefully removed by twisting it free — not by forcibly pull- 
ing it off, since this may accidentally cause removal of a 
portion of the blood column, by suction. The tube thus 
charged with blood is at once adjusted to one arm of the 
frame, and the empty tube similarly fixed in the other arm, to 
equalize the balance, this step being completed as rapidly 
as possible, in order to anticipate coagulation. When the 
tubes have been thus adjusted, and the frame securely locked in 
the spindle, the handle of the instrument is turned for three min- 




74 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

utes 1 at the rate of seventy-seven revolutions a minute, this rate of 
speed securing ten thousand rotations per minute of the frame, since 
the latter revolves one hundred and thirty times with each complete 
turn of the handle. The centrifugalization having been finished, 
the charged tube is carefully removed from the frame, and held 
against a piece of dull white paper, so that the height of the 
blood column may be easily determined. In order to make the 
reading with accuracy, it is sometimes necessary to use a small 
magnifying glass, for the divisions on the scale of the tube are 
but one-half a millimeter apart — a distance too small to judge 
easily with the naked eye. On examination, three distinct di- 
visions of the lumen of the tube containing the centrifugalized 
blood may be distinguished : first, a dark-colored column con- 
sisting of erythrocytes, reaching, in normal blood, to a point be- 
tween the divisions marked 50 and 51 ; second, a thin layer of 
leucocytes, showing, in blood in which these cells are not largely 
increased, as an indistinct, milky stratum overlying the erythro- 
cytes ; and, third, a layer of clear plasma occupying the remainder 
of the lumen. The normal volume of erythrocytes being arbi- 
trarily regarded as one hundred per cent., to compute this result 
the figure of the scale to which these cells rise is multiplied by 
two. Unless the leucocytes are greatly increased in number, the 
layer formed by these cells is too delicate and too dully defined 
to be read with any degree of accuracy ; but in cases of high 
leucocytosis and of leukemia it is quite possible to estimate roughly 
the relative proportions of leucocytes to erythrocytes. 

The capillary tube which has been filled with blood should be 
cleaned as soon after use as possible, water, followed by alcohol 
and ether, being used for this purpose. A fine wire should be 
passed through its lumen, to dislodge any obstruction which may 
result from drying of the column of closely packed corpuscles. 

The hematocrit, if its clinical application is limited to the de- 
termination simply of the relative volumes of the blood corpuscles 
and plasma, may be relied upon to furnish, on the whole, de- 
pendable information, the necessary errors attending its use 
probably being within two per cent. If employed in the role of 
a hemocytometer, however, its results must needs be highly inac- 
curate just in those instances in which exact methods of investiga- 
tion are all important. It is true that in normal blood, in which 
the size of the corpuscles ranges within the physiological limits, 
it is correct to consider each percentage volume as representing 

1 In a recent personal communication Dr. Daland advises that, in order to insure 
the most accurate results with his instrument, the centrifugalization be continued for 
three, instead of for two, minutes, as he formerly recommended. 



ESTIMATION OF THE SPECIFIC GRAVITY. 



75 



approximately a count of 100,000 erythrocytes per cubic milli- 
meter. In blood characterized by any considerable deformity in 
the size and shape of these cells, as in high-grade anemia or 
in leukemia, it is perfectly obvious that no such correspondence 
between the count and the percentage volume can be expected — 
blood in which microcytosis is pronounced is certain to show a 
lower percentage volume of erythrocytes than blood in which 
megalocytosis prevails, or than blood containing normal-sized 
cells, although the counts of all three may be identical. Similarly, 
a given number of lymphocytes should indicate a lower percentage 
volume than an equal number of myelocytes, or even polynuclear 
neutrophiles. On account of these sources of fallacy, if for no 
other reason, the hematocrit estimate should never be taken as a 
basis for calculating the count in pathological conditions, in lieu 
of the more accurate, if more laborious, method of counting the 
corpuscles. 

Capps 1 considers that the hematocrit may be used to advan- 
tage, in conjunction with the hemocytometer, in determining the 
actual size or volume of the individual erythrocyte, and he regards 
this method as far more reliable than the use of the micrometer, 
since with the latter only the transverse diameter of the cells, and 
not their depth, can be measured. The formula for calculating 
this "volume index" has been given elsewhere. (See p. 130.) 

VII. ESTIMATION OF THE SPECIFIC GRAVITY. 

This method of investigation is used as an indirect means of 
computing the percentage of hemoglobin, owing to the more or 
less constant parallelism maintained between it and the specific 
gravity of the whole blood. The correspondence between the two, 
together with the sources of error inseparable from the test, has 
been pointed out in another section. (See page 98.) 

Hammerschlag's modification 2 of Roy's 
Hammer- method 3 of determining the specific gravity of 
schlag's the blood best serves the purpose of those who 
Method. choose this roundabout means of approximating 
the hemoglobin percentage. It consists in first 
making a mixture of benzol and chloroform of such a specific 
gravity that a small drop of blood deposited in the liquid remains 
suspended, after which the specific gravity of the mixture is de- 
termined with a hydrometer, the figure thus obtained representing 

1 Journ. Am. Med. Assn., 1900, vol. xxxvi., p. 464. 

2 Zeitschr. f. klin. Med., 1 892, vol. xx., p. 444. 

3 Cited by Devoto : Zeitschr. f. Heilk., 1889, vol. xi., p. 175. 



y6 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

the density of the blood used in the test. The hemoglobin per- 
centage corresponding to this figure is then selected from a table 
giving the various degrees of blood densities and the percentages 
of hemoglobin to which they are equivalent. 

The apparatus required for making the test is neither elaborate 
nor expensive, a hydrometer provided with a scale graduated to 
1.070, a hydrometer jar having a wide, substantial base, a glass 
capillary tube, and a glass stirring rod being the only instruments 
needed. In most instances an ordinary urinometer may be used 
instead of a special hydrometer, since specific gravities in excess 
of 1060 (the highest gradation on the scale of most urinometers) 
are not often encountered. Either a Thoma-Zeiss leucocytom- 
eter, or a medicine dropper the free end of which should be 
heated in a flame and bent into an obtuse angle, will serve as a 
capillary pipette. 

Benzol and chloroform are mixed together in the hydrometer 
jar in such proportions that the specific gravity of the liquid is 
approximately equal to that of normal blood, 1060. This mix- 
ture having been made and its specific gravity taken, the point of 
the capillary pipette, charged with blood, is plunged beneath the 
surface of the liquid and a small bead of blood gently expelled. 
If the blood drop rises to the surface of the mixture a few drops 
of benzol are added, while if it sinks to the bottom of the jar 
chloroform is used, the addition of the appropriate reagent being 
continued until the drop neither rises nor sinks, but remains sta- 
tionary, suspended in the mixture. When this point has been 
determined the specific gravity of the liquid is taken by means of 
the hydrometer, this figure obviously representing the specific 
gravity of the blood drop itself. To translate the specific gravity 
into its hemoglobin equivalent the figure obtained by the above 
procedure is compared with one of the tables given on page 100. 
After each addition of benzol or of chloroform the contents of the 
jar must be thoroughly mixed by stirring with the glass rod, in 
order to secure uniformity in the density of the liquid. The latter, 
if it is filtered free from blood and preserved in a tightly stop- 
pered bottle, may be used again in subsequent tests. 

In spite of the enthusiasm evinced by certain authors for this 
method of ascertaining hemoglobin values, considerable experi- 
ence with the test has convinced the writer that it is both crude 
and untrustworthy, — it is useful, no doubt when a hemometer 
cannot be obtained, but in no sense is it an efficient substitute for 
colorimetric methods. The liability of the blood drop to split 
up into numerous fine particles, to adhere to the inside of the jar, 
and to become altered in composition from the influence of the 



ESTIMATION OF THE ALKALINITY. 



reagents, as well as the tedious attempts which must usually be 
made to add just the proper quantities of benzol and chloroform 
to secure a mixture in which the drop neither sinks nor rises, are 
a few of the drawbacks which must make the test unpopular with 
busy clinicians. 

VIII. ESTIMATION OF THE ALKALINITY. 

The most available clinical method of deter- 
Engel's mining the alkalinity of the blood is by the use 
Alkalimeter. of Engel's alkalimeter. ( Fig. 28. ) By means 
of this instrument a measured quantity of fresh 
blood is diluted with distilled water in the proportion of one to 
ten, and then titrated with a normal solution of tartaric acid 
until the mixture reacts with lacmoid paper, the total alkalinity 
being calculated from the amount of the tartaric acid used. The 
methods of alkalinity estimation devised by Landois 1 by Lieb- 
reich, 2 by Haycraft and Williamson, 3 by Wright, 4 and by Kraus, 5 
are not well adapted to routine blood-work, being either too com- 
plicated and elaborate for such a purpose, or too inaccurate. 

The apparatus which Engel has devised consists of the follow- 
ing parts : a diluting and mixing pipette, resembling a large-sized 
Thoma-Zeiss erythrocytometer ; a graduated burette by means of 
which the amount of tartaric acid solution used in the test is meas- 
ured ; a glass cylinder in which the titration is made ; and a glass 
stirring rod. The mixing pipette is graduated in three principal 
divisions marked 0.025, 0.05, and 5.0 respectively, the first two 
divisions being further scaled in tenths by fine horizontal mark- 
ings ; otherwise the instrument is modeled like a blood counting 
pipette. The burette has a capacity of five cubic centimeters, 
and is provided with a scale indicating one hundred equal divi- 
sions ; when in use, it is clamped upright, by means of a special at- 
tachment, to a vertical brass support which screws into a fitting 
in the box containing the apparatus. 

Method of Use. The technique of using the alkalimeter is 
simple and time saving in comparison with that required by other 
well-known methods of alkalinity testing. Finger-blood, ob- 
tained by a rather deep puncture so as to afford a good-sized drop, 
is sucked up in the pipette until it reaches the mark 0.05, imme- 
diately after which distilled water is similarly drawn up the lumen 

1 Real-Encyclop., 1885, vol. iii., p. 161. 

2 Berichte d. deutsch. chem. Gesellsch., 1868, vol. i., p. 48. 
3 Proc. of the Roy. Soc, Edinburgh, 1888, June 18. 

4 Lancet, 1897, vol. ii., p. 719. 
5 Zeitschr. f. Heilk., 1889, vol. x., p. 106. 



78 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

of the tube until the mixture of blood and water fills the bulbous 
expansion and reaches the mark 5.0, in the constricted portion 
beyond. While sucking up the water, the pipette should be rap- 
idly twisted to and fro between the thumb and forefinger, to insure 



Fig. 28. 




Engel's alkalimeter. 



thorough mixing of the blood and water as they together fill the 
expanded portion of the instrument. As soon as the dilution has 
been made, the pipette should be shaken for a minute or so, until 
the mixture becomes of an uniform " laky " tint, which indicates 
that all the hemoglobin has been dissolved from the corpuscular 
stroma. The contents of the pipette are blown out into the glass 
cylinder, which is placed beneath the faucet of the burette, the 
latter having been previously filled to the mark o with a y 1 -^ nor- 
mal solution of tartaric acid. By turning the stop-cock of the 
burette, the test solution is now added, drop by drop, stirring be- 
tween each addition, to the measured amount of diluted blood 
in the cylinder. From time to time a drop of the mixture is re- 
moved by means of the glass rod and tested with the lacmoid 
paper, the titration being continued until the reaction, recognized 
as a bright red halo which forms around the edge of the drop, is 



DETERMINATION OF RAPIDITY OF COAGULATION. 



79 



obtained. The titration is then stopped, and a note made of the 
number of drops of the test solution which have been used. In 
normal blood the writer finds that from 9 to 1 1 drops are re- 
quired to give the reaction. The estimate of the total alkalin- 
ity of the blood is made by multiplying by the figure 53.3, the 
number of drops of the tartaric acid solution used, according to 
the formula, 10 : a : : 533.0 : x, a representing the drops of the 
reagent. 1 The result thus obtained is expressed in milligrammes 
per hundred cubic centimeters of blood. The following table may 
be useful for reference in determining the various degrees of 
alkalinity : 

If 6 drops of the solution are used the alkalinity equals 319 mgrms. NaOH 

" " " " " 373 



43 6 
479 
533 
586 

639 
692 
746 



After use the pipette should be thoroughly washed out with 
water, alcohol, and ether, and then dried, in the manner already 
directed for cleaning the Thoma-Zeiss instrument. 

While, up to the present time, it cannot be claimed that infor- 
mation of any real diagnostic pertinence has been obtained from 
the study of the alkalinity of the blood, this procedure should 
prove of value in the systematic investigation of many cases, espe- 
cially those of high-grade anemia. As elsewhere mentioned, the 
degree of normal blood alkalinity varies greatly according to the 
particular method by which this figure is ascertained, so that it 
follows that the results obtained by means of Engel's apparatus 
cannot be compared with those based upon different methods of 
research. 

IX. DETERMINATION OF THE RAPIDITY OF 
COAGULATION. 

This procedure is obviously more useful in experimental labora- 
tory work than as a means of clinical investigation, yet in some 
diseases, such as hemophilia, it will prove of real value, since in 

1 Assuming that 0.5 cc. of tartaric acid are used to neutralize 0.05 cc. of blood, 
therefore for every 100 cc. of blood 1,000 cc, or one liter, of a y 1 - normal solution of 
tartaric acid are required. As the alkalinity of the blood is not expressed by the 
amount of acid necessary to saturate it, but in milligrammes of an alkali, sodium hy- 
drate, the calculation is made thus : as the equivalent weight of tartaric acid is 75, 
and that of sodium hydrate 40, one liter of water dissolving 75 grammes of the for- 
mer saturates 40 grammes of the latter, that is, one liter of a y 1 - normal tartaric acid 
solution saturates grammes, or, in other words, 533 milligrammes, of sodium hy- 
drate, this figure being taken by Engel as the degree of normal alkalinity of the blood. 



80 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 



this condition it is possible thus to determine the influence of 
remedies administered with a view to promoting coagulation of 
the blood. In a number of other pathological conditions, char- 
acterized either by delay or by unusual rapidity of coagulation, 
this method of research furnishes information which at least adds 
completeness to the clinical histoiy, if nothing more. 

The coagulation time may be determined ap- 
Glass Slide proximately by collecting several individual drops 
Method. of blood of the same size upon the surface of a 
perfectly clean, slightly warmed glass slide. At 
regular intervals of about one minute a straw of a whisk-broom is 
lightly trailed through each drop in succession, until sooner or 
later a delicate thread of fibrin may be observed clinging to the 
straw. The period which has elapsed between the deposit of 
the blood on the slide and the appearance of this indication of 
clotting is expressed in minutes, to represent the coagulation 
time of the specimen under investigation. Normal blood thus 
treated coagulates in from two and one-half to five minutes. 

This instrument (Fig. 29) consists of a tin 
Wright's Co- water can surrounded by a flannel-lined leather 
agulometer. jacket provided with nine pockets, one of which 
is intended to hold a thermometer, and the others 
a set of glass coagulation tubes. The latter are each about 10 
centimeters in length, with a lumen 0.25 millimeter in diameter, 
and are open at both ends ; they should be con- 
secutively numbered or lettered, in order that they 
may be distinguished apart at a later stage of the 
test. The thermometer is of the same outer di- 
ameter as that of the tubes, and registers the 
same degrees of temperature as an ordinary clin- 
ical thermometer. 

Method of Use. The central receptacle is first 
filled with water having a temperature of about 
99 0 F., and the tubes slipped into the pockets sur- 
rounding it, being allowed to remain in them for 
a few minutes, so that they may become warmed 
to the temperature of normal blood. Having 
then pricked the patient's finger, each tube is 
about half filled with blood, by aspiration, at suc- 
cessive intervals of one minute, a tube as soon 
as it is filled being replaced in its appropriate 
pocket. An equable temperature of the tubes 
should be maintained by the addition of hot water to the can, 
as its contents cool. Within three minutes after filling the first 



Fig. 




29. 



Wright's coagu- 

LOMETER. 



SPECTROSCOPIC AL EXAMINATION. 



Si 



tube, it should be tested, by blowing out its contents upon the 
surface of a sheet of white filter-paper, the remaining tubes being 
similarly tested at regular intervals of one minute or less, until 
after thus trying a variable number, one is found from which the 
blood cannot be expelled. Coagulation may then be con- 
sidered to have occurred, the time required for this process 
being expressed by the number of minutes elapsing between the 
filling of the tube in question and the evidence of clotting thus 
demonstrated. With normal blood the coagulation time, as de- 
termined by this instrument, ranges from about three to five 
minutes. 

xAfter use, a fine wire should be forced through the lumen of 
the tubes, to dislodge the clots, after which the remaining traces of 
blood are to be removed by thorough washing with distilled water, 
alcohol, and ether, in the order named. 



X. SPECTROSCOPICAL EXAMINATION 



For clinical work the Sorby-Beck microspectroscope, to be used 
in connection with the microscope, is an excellent instrument, 
being both accurate, and, comparatively speaking, easy to manip- 
ulate. Other very perfect instruments for the spectroscopical 
examination of the blood, differing but 
little from the original Sorby model, are Fig. 30. 

also made by Zeiss, by Leitz, and by 
Browning. 

This instrument (Fig. 
The 30) when in use fits into 
Sorby-Beck the tube of the micro- 
Microspectro- scope, like an ordinary 
scope. ocular, for which it is 
substituted. Its essen- 
tial part consists of a tube, A, in which 
a series of five prisms, two of flint and 
three of crown glass, is arranged in such 
a manner that the emergent rays, which 
are separated by dispersion, leave the 
prisms in practically the same direction s< 
as that taken by the entering immer- 

gent ray. At one side of the tube is fixed a right-angle reflecting 
prism, so that the spectrum of a solution of normal blood may be 
thrown alongside that of the specimen under investigation, the 
two spectra thus being comparable. The adjustment of the 
spectra is effected by means of the two small screws, B, B' . The 
6 




>rby-Beck microspectroscope. 



82 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 



receptacle containing the control solution of blood is clamped to 
the stage, C, by a spring clip, D, light being reflected through 
the liquid and into the rectangular aperture, E, by the swinging 
mirror, F. The width of this aperture is controlled by the 
screw, G. The receptacle containing the blood solution to be 
examined is placed upon the stage of the microscope, being 
brought into focus with a low-power or I inch) dry objective. 
Beneath the tube enclosing the series of prisms is mounted an 
achromatic ocular, below which a narrow slit-like diaphragm is 
situated, the vertical size of this opening being regulated by a 
milled screw, not shown in the illustration, and its breadth by the 
two small levers, /, P . Both ocular and prisms may be moved 
simultaneously toward and away from the diaphragm, by a 
rack-and-pinion mechanism controlled by the 
Fig. 31. wheel, J, so that any part of the spectrum may 
be brought into focus. 

The liquids to be examined should be placed 
in Sorby's tubular cells, and cover-glasses super- 
imposed. These cells (Fig. 31) are narrow- 
lumened glass receptacles made of barometer 
tubing, both ends of which are accurately ground to parallel 
surfaces, one end being cemented to a small polished glass 
plate. 

Method of Examination. The specimen of blood obtained in 
the usual manner, by puncture, is first diluted with distilled water 
one hundred times, by means of the Thoma-Zeiss erythrocy- 
tometer, and sufficient of this laked blood dropped into a Sorby 
cell to fill it exactly to the brim. A cover-glass is then carefully 
laid over the open end of the cell, the precaution being taken to 
prevent the formation of air-bubbles upon the surface of the 
column of liquid thus enclosed. A second cell, to be used as 
the control, is filled with normal blood, similarly diluted, and 
both are then adjusted in their respective positions, as already 
explained. 

In making the examination, a ray of artificial light (that from 
a Welsbach incandescent burner being most suitable) is projected 
by the microscope mirror through the lumen of the cell contain- 
ing the suspected blood, and the surface of the liquid focused 
with an ordinary ocular. The latter is then removed from the 
microscope tube and replaced by the spectroscope ocular, and 
the second spectrum, that of the normal blood, is brought into 
proper position alongside that of the first, so that any differences 
between the two may be contrasted by the observer. 

The appearance of the spectra of normal and of pathological 




BACTERIOLOGICAL EXAMINATION. 



83 



blood, together with the circumstances under which the latter 
occur, have been described in another section. (See page 123.) 

XL BACTERIOLOGICAL EXAMINATION. 

The demonstration of bacteria in the circulating blood, pro- 
vided that faultless technique is employed, furnishes in some 
instances a diagnostic sign of the greatest importance. The 
pathological significance of such a finding is much greater than 
that of a similar result obtained post-mortem, since with the 
latter there is no means of determining whether the bacterial 
invasion of the blood current took place during the active stages 
of the disease, or whether it occurred either as a pre- or a 
postagonal process. 

Cultural methods with blood aspirated directly 

Methods. from a superficial vein should invariably be used 
whenever such a procedure is practicable, for 
blood obtained simply by pricking the skin is most likely to be 
contaminated with various bacteria which have their normal hab- 
itat in the epidermis and its appendages, notably by the staphyl- 
ococcus epidermidis albus. Welch, 1 who first drew attention to 
this source of error, emphasizes the fact that no diagnostic sig- 
nificance should be attached to the demonstration of this bac- 
terium in blood obtained by puncture of the skin. 

Direct examination of stained cover-glass specimens prepared 
from finger blood gives either negative or erroneous results in the 
great majority of instances. In certain overwhelming infections, 
notably in some of the severer forms of bubonic plague, it may 
often be possible to detect the specific micro-organism in the 
stained film, but the method must be regarded as too crude and 
unreliable to furnish accurate findings, in the average case. 

Blood Cidtures. In order to secure the most reliable informa- 
tion from blood culturing, the systematic observance of three pre- 
cautions is essential. First, contamination by the skin bacteria 
above referred to must be carefully avoided, by the thorough ster- 
ilization of the patient's skin at and adjacent to the site from which 
the blood is aspirated. Second, not less than 0.5 cubic centimeter 
of blood should be used for each culture, since only in rare in- 
stances are bacteria so numerous in the peripheral circulation as 
to be demonstrable in a single drop of blood. Third, fluid, rather 
than solid, culture media should be used, in sufficiently large 
quantities to dilute the blood freely — about one hundred parts of 
media to each part of blood — the object of this precaution being 

1 Dennis' System of Surgery, Phila., 1895, vol. i., p. 251. 



84 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

to secure attenuation of the bactericidal properties of the blood, 
which otherwise might prove strong enough to prevent all bac- 
terial development. 

For aspirating the blood the author prefers to use the needle- 
capped glass tube devised for this purpose by James and Tuttle. 1 
(Fig. 32.) This consists of a piece of glass tubing five inches in 
length and one-quarter of an inch in diameter, having a capacity 
of about two cubic centimeters ; it is tapered at one end and 
ground to fit the cap of a number 42 hypodermic needle, while 
the free end of the tube is plugged with a bit of cotton. The ap- 
paratus is enclosed in a larger glass tube both open ends of which 
are also plugged with cotton, and sterilized by dry heat, the aspi- 
rating tube being removed at the time the blood is to be collected. 
This instrument is far superior to an antitoxin or a hypodermic 
syringe for the purpose intended, being simple, inexpensive, easily 

Fig. 32. 




Needle and tube for aspirating blood for culturing. 

sterilized, and readily cleaned after use. It is especially well 
adapted for making cultures at a distance from a laboratory, where 
the sterilization of an ordinary piston-syringe is difficult, if not 
impossible. 

At least six hours before the aspiration of the blood, the skin 
of the patient's arm at and for some distance on all sides of the 
bend of the elbow should be thoroughly scrubbed for several 
minutes with either a strong ethereal soap or with tincture of 
green soap, after which the part is well rinsed with hot sterile 
water, and finally washed with alcohol and ether. A moist I : 
500 bichloride compress is then applied over the site thus cleaned, 
being left in place until the time of the withdrawal of the blood. 
As a preliminary to this operation, the dressing is removed, and 
the part freely douched and scrubbed with hot sterile water, in 
order to remove eveiy trace of the bichloride. A rubber drain- 
age tube, previously sterilized, is twisted tightly around the pa- 
tient's arm above the bend of the elbow so as to cause disten- 
tion of the superficial veins in this situation, and the point of the 
needle is then thrust obliquely into the most prominent of these 

1 Med. and Surg. Reports of the Presbyterian Hosp., N. Y., 1898, vol. iii., 
p. 46. 



BACTERIOLOGICAL EXAMINATION. 



85 



vessels, with the result that the blood immediately begins to flow 
into the bore of the instrument. If, for any reason, the force of 
the blood flow should fail to fill the caliber of the tube, sufficient 
blood may be easily obtained by making gentle suction through 
a bit of rubber tubing slipped over the cotton-plugged end of the 
instrument. While introducing the needle it should be held 
almost parallel to the long axis of the vein, for should it be 
simply plunged into the vessel at right angles, there is danger 
that the point will pass completely through the vessel from wall 
to wall and penetrate the surrounding tissues — an accident which 
may explain the cause of many a " dry-tap." The site of the as- 
piration may be made anesthetic by preliminary freezing with 
a spray of ethyl chloride, but to most patients the operation is not 
painful enough to necessitate such a procedure. 

Having thus collected, say, two cubic centimeters of blood, the 
contents of the tube are divided equally among four Pasteur flasks 
each containing at least fifty cubic centimeters of broth or other 
suitable fluid culture media. The flasks are then shaken for a 
few moments, in order to mix the blood and media and to dilute 
thoroughly the former, after which they are placed in an incu- 
bator. The identity of the growths, should any occur, remains 
to be determined by secondary culturing and microscopical ex- 
amination, for descriptions of which the student should consult 
text-books on bacteriology. Cultures made by this technique, 
suggested by Adami, 1 are much more favorable to the growth 
of any bacteria which may be in the blood-stream than the older 
methods of using solid media. 

Staining Methods. In the limited number of instances to which 
such methods are applicable the technique described below will be 
found useful. 

An attempt should be made to sterilize the skin of the finger 
from which the blood is obtained, by thoroughly scrubbing the 
part first with ethereal or green soap, and then with a 1:500 
bichloride solution, alcohol and ether, in the order named, this 
being followed by sponging with sterile water. A deep punc- 
ture having been made with a needle which has been sterilized 
by the naked flame, and the first few drops of blood escaping 
from the wound allowed to drip away, one of the succeeding 
drops is transferred by means of a sterile platinum needle to the 
surface of a cover-glass upon which a second cover-glass is 
at once laid, the two being drawn apart, in order to secure a 
pair of spreads. The latter are immediately dried by gentle heat 
and then passed several times through a Bunsen flame. It is 

1 Journ. Am. Med. Assn., 1899, vol. xxxiii., p. 1514. 



86 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 



needless to add that the cover-glasses used for making the films 
must be sterilized by heat, and handled by means of a pair of 
sterile forceps. Films thus prepared may be stained with any of 
the basic aniline dyes (thionin, methylene-blue, and methyl- or 
gentian-violet being most useful for this purpose), after which 
they are washed in water, dried, and mounted in Canada balsam 
or in cedar-oil. Should a double stained specimen be desired, 
one of theeosin and methylene-blue solutions referred to previously 
may be depended upon to give satisfactory results. 

Gimther's method 1 will be found useful, if the object is to de- 
stroy the color of the erythrocytes, so as to leave a freer field of 
vision for any bacteria which may be present in the film. Ac- 
cording to this method, the specimen is first immersed for ten 
seconds in a five per cent, aqueous solution of acetic acid, until 
the tint of the hemoglobin has entirely faded away, after which 
the reagent is removed by briskly blowing upon the surface of 
the cover-glass ; the latter is then held, face downward, over the 
open mouth of a bottle containing strong ammonia water, so as 
to neutralize all remaining traces of the acid. The film is now 
stained for twenty-four hours with the Ehrlich-Weigert fluid 
(contained in a covered staining dish), at the end of which time 
it will be found to be colored a deep blue. It is then decolorized 
by a few seconds' immersion in a 1:14 aqueous solution of nitric 
acid, until the color fades to a light green ; rinsed in alcohol ; 
dried in air ; and mounted in balsam. 

The Ehrlich-Weigert fluid is prepared by adding from 10 to 
15 drops of aniline oil to 6 cubic centimeters of distilled 
water, held in a test-tube. The fluid is thoroughly mixed by 
shaking, and then filtered. To the filtrate a few drops of a con- 
centrated alcoholic solution of methyl- or gentian-violet is added 
— just sufficient of the dye to produce a slight turbidity of the 
liquid, which clears up in a few minutes. The mixture prepared 
in this manner is employed as the staining agent. 

XII. DETERMINATION OF THE SERUM REACTION. 

In 1894 Pfeiffer 2 noticed that the vibrios of 
Widal's Asiatic cholera, if injected into the peritoneal 
Test. cavity of a guinea-pig immunized against this 
disease, rapidly lost their characteristic motility, 
and tended to become granular, broken up, and dissolved, while 

iForschr. d. Med., 1885, vol. iii., p. 775. 

2 Zeitschr. f. Hyg., 1894, vol. xviii., p. I. Ibid., 1895, vol. xix., p. 75. 
Also, Centralbl. f. Bakt. u. Parasitenk., 1896, vol. xix., p. 191. Also, Deut. med. 
Woch., 1896, vol. xxii., p. 97. 



DETERMINATION OF THE SERUM REACTION. 



87 



in the healthy, non-immune animal they developed normally and 
abundantly, and failed to show any such changes in their mor- 
phology. He claimed that this reaction, known as " PfeifTer's 
phenomenon," was specific, and emphasized its value as a means 
of laboratory differentiation. Two years later Pfeiffer and Kolle 1 
found that the same changes occurred in experiments with the 
bacillus of Eberth and animals rendered immune to enteric fever, 
and, furthermore, discovered that the test could be conducted in 
vitro, by mixing in a test-tube typhoid cultures and immune serum. 
It is of interest to note that results somewhat analogous to those of 
Pfeiffer had been observed in 1891 by Metchnikoff, 2 and in 1889 
by Bordet, 3 and by Charrin and Roger, 4 although none of these 
workers appeared to recognize the significance of their observations. 

In 1896 Griiber and Durham 5 applied the principles of Pfeif- 
fer's phenomenon to many other motile as well as non-motile 
bacteria, deduced new facts regarding its utility as a means of 
differentiating various species of germs, improved the technique 
of the test, and made the important announcement that aggluti- 
nation and immobility of typhoid bacillus cultures were pro- 
duced by the action of blood serum from a patient having re- 
cently recovered from an attack of enteric fever. It remained, 
however, for Widal, 6 in 1896, first to apply the reaction clinically, 
and to announce that enteric fever could be diagnosed by noting 
the clumping and immobilization of the typhoid bacillus when 
mixed in definite proportions with blood serum from a patient 
suffering from typhoid. This reaction, Widal insisted, was one of 
infection, and was demonstrable not only during convalescence, 
but during the incipiency and the height of the disease. 

The serum reaction is to-day recognized as an important sign 
in the diagnosis not only of enteric fever, but also of Asiatic 
cholera, of Malta fever, and of relapsing fever, while its value still 
remains less certainly established in many other conditions, such 
as, for example, leprosy, tuberculosis, yellow fever, bubonic 
plague, and pneumococcus infections. The technique of the test 
and its diagnostic significance under various circumstances, will 

1 Zeitschr. f. Hyg., 1896, vol. xxi., p. 203. Also, Deut. med. Woch., 1896, 
vol. xxii., p. 735. 

2 Annal. de l'lnstitut Pasteur, 1891, vol. v., p. 473. Ibid., 1894, vol. viii., 
p. 714. Ibid., 1895, vol. ix., p. 433. 

3 Annal. de l'lnstitut Pasteur, 1895, vol. ix., p. 462. Ibid., 1896, vol. x., 
p. 191. 

4 Compt. rend. Soc. Biol., 1889, 9 s., vol. L, p. 667. 
5 Munch, med. Woch., 1896, vol. xliii., p. 285. 

6 Bull, med., 1896, vol. x., pp. 618 and 766. Sem. med., 1896, vol. xvi., 
p. 259. Ibid., 1897, vol. xvii., p. 69. Lancet, 1896, vol. ii., p. 1371. Munch, 
med. Woch., 1897, vol. xliv., p. 202. 



88 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. 

be described under the headings of the diseases in which it occurs. 
(See " General Hematology.") 

Originally Bordet, 1 more recently Uhlenmuth, 2 

The Specific and Wassermann and Schutze 3 have demon- 
Test for strated the important fact that the blood serum 

Human Blood of an animal subcutaneously injected with the 
blood of another animal of a different species 
rapidly develops the property of agglutinating and dissolving the 
eiythrocytes similar to those injected, but has no effect upon 
blood derived from any other source. The last-named ob- 
servers, for example, administered to rabbits, at intervals of two 
days, several subcutaneous injections of 10 cubic centimeters 
each of defibrinated human blood, the animals being bled to 
death six days after the last dose, and their shed blood placed 
upon ice, to effect separation of the serum. Sufficient blood for 
this purpose may be readily obtained by wet-cupping, leeching, 
or placental expression. If 0.5 cubic centimeter of this rabbit- 
serum (or " antiserum" for human blood) is added to a solution 
of the blood of man, diluted about one hundred-fold with distilled 
water or with normal salt solution, a distinct cloudy precipitate 
rapidly occurs at ordinary room temperature, the turbidity be- 
coming much more dense after brief incubation of the mixture at 
37° C. On the contrary, no definite change occurs on the ad- 
dition of the serum to the diluted blood of other animals, no 
less than twenty-three different species having failed uniformly to 
react positively, with the single exception of the monkey, and in 
this instance the reaction was delayed and incomplete, being in 
no way comparable to the prompt cloudiness produced by the 
mixture of human blood with its antiserum. Old dried, and even 
putrefied blood, diluted 1 to 100 with normal salt solution, has been 
found to react typically, while Nuttal and Dinkelspiel 4 have re- 
ported characteristically positive results with human blood mixed 
with an equal volume of the diluted blood of different animals, 
such as sheep, oxen, horses, and dogs. These workers also found 
that positive results were obtained with human nasal and lachrymal 
secretions. Uhlenmuth 5 discovered that blood specimens could 
be frozen for two weeks at a temperature of io° below zero, C, 
without in any way affecting the sensitiveness of the reaction, 
and that blood mixed with soapy water, menstrual urine, and 
other contaminating liquids responds promptly and typically. 

iAnnal. de 1'Institut Pasteur, 1898, vol. xii.,p. 688. Ibid., 1899, vol. xiii., p. 273. 
2 Deut. med. Woch., 1901, vol. xxvii., p. 82. 
3 Berl. klin. Woch., 1 901, vol. xxxviii., p. 187. 
4 Brit. Med. Journ., 1901, vol. i., p. 1141. 
5 Loc. cit. 



DETERMINATION OF THE SERUM REACTION. 



8 9 



From a medico-legal standpoint, the value of this test is ob- 
vious, for, even at this early stage of its development, it has 
received sufficient corroboration to justify its use as a means of 
identifying human blood stains, no matter how old and how 
contaminated they may be. For this purpose, the reaction ap- 
pears to be entitled to much greater confidence than the spec- 
troscope, or chemical tests. 



SECTION II. 



THE BLOOD AS A WHOLE. 



SECTION II. 



THE BLOOD AS A WHOLE. 



I. GENERAL COMPOSITION. 

Blood is a tissue consisting of fluid and cor- 
Plasma, Serum puscular elements, the former constituting about 
and Cells, three-fifths, and the latter two-fifths of its total 
volume. It has been approximated that the total 
quantity of blood in the normal individual is from y 1 ^ to of the 
body-weight, the proportion being somewhat less in the infant 
than in the adult. The fluid element of the blood, known as the 
plasma or liquor sanguinis, is an alkaline, yellowish liquid, of 
a specific gravity ranging from about 1026 to 1030, and con- 
taining approximately ten per cent, of solid matter, of which 
three-fourths are proteids ; the latter consist of fibrinogen, 
serum-albumin, and serum-globulin. Coagulation of the blood 
results in its separation into a densely reticulated, somewhat 
granular substance, fibrin, and into a clear, straw-colored, alka- 
line fluid, serum. Fibrin is a sparingly soluble, highly elastic, 
proteid body, which encloses and imprisons within its multitude 
of delicate fibrils the corpuscular elements, the whole forming the 
blood-clot or crassamentum. Serum is a clear, straw-colored, alka- 
line fluid, having a specific gravity of about 1026 and containing 
practically the same amount of solids and relative proportion of 
proteids as are found in the plasma ; its proteid constituents are 
fibrin-ferment, which replaces the fibrinogen of the plasma, serum- 
albumin, and serum-globulin. 

The corpuscular elements of the blood are free cellular bodies 
suspended in the plasma. They are of two varieties : the eryth- 
rocytes or red corpuscles, and the leucocytes or white corpuscles. 
In addition to these cells, two other elements are also found, 
namely, the blood-plaques, and the hemoconia, although these 
bodies, while they may be conveniently grouped with the red and 
white cells, are not to be regarded as definite corpuscular entities. 

The salts of the blood include sodium chloride, potassium 
chloride, sodium carbonate, sodium phosphate, magnesium phos- 
phate, calcium phosphate, and sulphates ; of these salts sodium 
chloride is the most abundant, constituting from 60 to 90 per 
cent, of the total amount of mineral matter. 



94 



THE BLOOD AS A WHOLE. 



Certain extractives are also found, among which are urea and 
uric acid, creatine, creatinine, xanthine, hypoxanthine, sugar, fats, 
soaps, and cholesterine. 

The gases of the blood consist of oxygen, nitrogen, and carbon 
dioxide, the former existing chiefly in combination with hem- 
oglobin in the erythrocytes, and the latter as carbonates ; the 
nitrogen is held in simple solution. About 60 volumes of gas are 
contained in each 100 volumes of blood. Arterial blood contains 
roughly 20 volumes of oxygen, and 40 of carbon dioxide, while 
venous blood contains less than 10 volumes of oxygen, and almost 
50 of carbon dioxide ; the quantity of nitrogen in both arterial 
and venous blood is from 1 to 2 volumes. . 

II. COLOR. 

The distinctive color of the blood is due to 
Normal the presence of the hemoglobin contained in the 
Variations, erythrocytes, and alterations in the chemical com- 
position of this pigment produce corresponding 
changes in the color of these cells, and, consequently, in the 
naked-eye appearance of the whole blood. The color of arte- 
rial blood is bright scarlet, inasmuch as it contains a large amount 
of oxygen in chemical combination with the hemoglobin ; while 
venous blood, on the other hand, is of a dark purplish-blue tint, 
owing to its deficiency in oxygen and to the presence of more or 
less uneliminated carbon dioxide. This difference in color is so 
obvious that a cursory glance suffices to distinguish arterial and 
venous bloods. 

The presence of immense numbers of hemo- 
Density globin-containing elements accounts for the vary- 
and ing degree of density and opacity which the 
Opacity. blood possesses, distinguishing it from a mere 
transparent, colored fluid. If, for any reason, the 
hemoglobin escapes from the erythrocytes into the surrounding 
plasma, this characteristic opacity is quickly lost, and the blood 
becomes transparent, and of a u laky " color. The density and 
the opacity, and, consequently, the color of the blood increases and 
diminishes according to the fluctuations which occur in the relative 
amounts of plasma and erythrocytes, and also according to the cells' 
richness in hemoglobin, irrespective of their numerical variation. 

In anemic conditions the blood is usually pale 
Pathological in color, somewhat transparent, and thin and 
Variations, watery-looking. This is the case particularly in 
primary pernicious anemia, in chlorosis, and in 
leukemia ; in the former disease, it is sometimes difficult to believe 



REACTION. 



95 



that the watery, pale fluid which flows from the puncture is any- 
thing but pure serum ; in leukemia, the blood drop may have a 
peculiar light, mottled, streaked appearance, or an uniform milky- 
white tint may predominate over the normal red hue. In cases 
of dyspnea, arterial blood, because of its inadequate oxygenation, 
may be dark blue, closely resembling blood from the veins. This 
similarity has also been noted in cases of poisoning by sulphur- 
etted hydrogen, in which condition the blood may even be changed 
to a dark greenish tint. In some cases of diabetes mellitus, the 
presence of large quantities of free fat in the circulation seem- 
ingly divides the blood drop into two distinct layers, an upper, 
light-colored portion, containing supernatant fat-droplets, and a 
lower, darker layer of pure blood ; at first glance diabetic blood 
has a somewhat pinkish hue. 

In poisoning by aniline, nitrobenzol, hydrocyanic acid, and potas- 
sium chlorate, the blood is chocolate- or dun-colored ; and in 
poisoning by carbon monoxide, bright cherry- red. In severe 
icterus a yellowish-red tint of the blood has been observed. 

III. ODOR AND VISCOSITY. 

Owing to the presence of certain volatile fatty acids, blood 
possesses a peculiar and characteristic odor or halitus, which may 
be intensified by the addition of concentrated sulphuric acid, and 
which rapidly disappears after the withdrawal of the blood from 
the body. The slippery feeling of freshly drawn blood is quickly 
lost after its exposure to the atmosphere, and is replaced by a 
viscosity or stickiness, as coagulation progresses. 

IV. REACTION. 

- Under normal conditions, the reaction of the 
Reaction blood is alkaline, owing chiefly to the presence 
in Health, of sodium carbonate and disodium phosphate. 

Clinically, the degree of alkalinity is determined 
by ascertaining the amount of sodium hydroxide which is ex- 
actly neutralized by one hundred cubic centimeters of blood, the 
result being usually expressed in milligrammes of NaOH per 
hundred cubic centimeters of blood. The figures given by differ- 
ent investigators as representing the normal alkalinity range 
within the widest limits, chiefly in consequence of the many dif- 
ferent methods by which such data were obtained. In view of 
these marked discrepancies, the alkalinity figures of different 
workers are in no sense comparable unless they are based upon 
precisely similar methods of investigation pursued with identical 



9 6 



THE BLOOD AS A WHOLE. 



technique. The following table, compiled from reliable data, il- 
lustrates the range of the normal blood alkalinity, as estimated 
by various observers : 



Observer. Degree of Alkalinity. 

Kraus 162-232 mgrms. NaOH per 100 cc. of blood. 

Burmin 182-218 " << " " « « " 

RumpfF. 182-218 " " " " " <f " 

Jeffries 200 " " " " " " " 

Freudberg 200-240 " " " " " " " 

Lepine 203 " " " " " " " 

Canard 203-276 " " " " " " " 

Drouin 206 " " " " " " " 

Von Limbeck 218 " " " " " " " 

Zuntz and Lehmann 240 " " " " " " " 

Von Jaksch 260-300 " " " " " " " 

Scbultz-Scbultzenstein 260-300 " " " <; " " " 

Strauss 300-350 " " " " " (l 11 

Brandenburg " " " " " " " 

Lowy 449 " 11 " " " " " 

Berend 450-500 " " " " " " " 

Engel 479-533 " " " il " " " 

Mya and Tassinari 516 " " " " " " " 



With the titration method, now generally admitted to furnish 
fairly accurate results, appreciably higher figures are obtained 
with laked whole blood than with serum alone, since by the 
former method the alkalinity of all the plasma and cellular ele- 
ments is estimated, while by the latter the influence of the cor- 
puscles is entirely eliminated. 

The alkalinity of the blood is slightly higher, 
Physiological as a general rule, in men than in women and 
Variations, children, and is somewhat influenced by the time 
of day, being at its minimum during the early 
morning hours, gradually rising during the afternoon, and falling 
again during the evening. Some observers maintain that it is 
increased during the period of digestion, but this fact is dis- 
puted by others. It is temporarily diminished by the effects of 
muscular exercise, and by a diet deficient in nitrogenous substances ; 
on the contrary, richly nitrogenous food eaten during the per- 
formance of muscular work overcomes the effect of such exertion 
in lowering the alkalinity. The effects of cold baths are said to 
increase the alkalinity of the blood. 

In health, by the perfect mechanism of the emunctory organs 
of the body, the normal balance of blood alkalinity is constantly 
maintained, in spite of the entrance of acids into the blood, 
whether by the ingestion of acid substances, or by their produc- 
tion within the system, for the excess acidity from such causes 
is promptly removed from the blood by the action of the kidneys, 



REACTION. 



97 



the skin, and the lungs. Thus, the ingestion of acids is quickly 
followed by increased acidity of the urine and sweat, while at the 
same time an increased quantity of carbon dioxide is given off by 
the lungs. It is also probable that the tendency to acidity is 
partly neutralized by the ammonium salts generated from proteid 
foods, and by the action of the liver. 

Increased alkalinity goes hand in hand with increased antidotal 
actioyi of the blood against bacterial infection, as experiments have 
shown that animals whose blood had been artificially rendered 
highly alkaline, by the administration of sodium salts, showed 
much greater resistance to the effects of virulent micro-organisms, 
than untreated animals. Therefore, it is believed that the power 
of immunity against infections may, to a certain degree, be meas- 
ured by the alkalinity of the blood, for, in animal experimenta- 
tion, the fact is evident that the greatest degree of blood alka- 
linity is found in animals whose immunity is absolute. 

Unfortunately, the question of alteration in the 
Pathological alkalinity of the blood in various pathological 
Variations, conditions is at the present time one about which 
the opinions of different observers conflict, so 
that conclusions concerning this subject must be accepted with 
more or less reserve. 

It is of interest, however, to note that most observers agree 
that, as a rule, the alkalinity of the blood is perceptibly lowered in 
those diseases associated with a febrile movement, but no definite 
relation between the intensity of the pyrexia and the degree of 
lessened alkalinity has been established. Subnormal alkalinity 
figures have also been met with in the primary and secondary ane- 
mias, with the exception of chlorosis, in which condition the blood 
alkalinity usually is either normal, or perhaps slightly increased. 
Desevres 1 has drawn attention to the fact that in the early stages 
of acute diseases the alkalinity is either normal or somewhat in- 
creased, and in the majority of instances it becomes perceptibly 
diminished during convalescence. In chronic diseases it is usu- 
ally decreased if the duration of the disease has been of long 
standing. 

Drouin 2 found a lessened alkalinity of the blood in enteric 
fever, in pneumonia, in malarial fever, in diphtheria, in rheumatic 
fever, in erysipelas, in appendicitis, and in many other acute infec- 
tions. Cantani 3 maintains that in the algid stage of Asiatic chol- 
era the reaction of the blood during life in some cases may be 

1 These de Lyon, 1897-98. 

2 " Hemo-alcalimetrie et Hemo-acidimetrie," These de Paris, 1892, n. 83. 
3 Centralbl. f. d. med. Wissensch., 1884, vol. xxii., p. 785. 

7 



9 8 



THE BLOOD AS A WHOLE. 



even acid, and that the alkalinity is always markedly reduced. 
Von Jaksch, 1 Peiper, 2 Kraus, 3 and others state that the alkalinity 
is generally diminished in uremia, in diabetes, in osteomalacia, in 
organic diseases of the liver, and in poisoning by carbon mon- 
oxide and by phosphorus, especially by the latter. Decreased 
alkalinity has also been noted in cholemia, in Addison 's disease, 
in Hodgkin's disease, in poisoning by mineral acids, in the late 
stages of malignant neoplasms, and in various long-standing 
cachectic conditions. Thomas 4 found the alkalinity reduced in 
acute alcoholism^ and as the result of chloroform narcosis. Tchle- 
norff 5 found a diminished alkalinity in a wide variety of skin 
diseases, among which are named psoriasis, eczema, pemphigus, 
purpura hemorrhagica, erythema multiforme , lichen rubra, and 
elephantiasis. Since it was also found that the administration of 
arsenic failed to increase the blood alkalinity, the action of this 
drug upon dermatoses is evidently not due to its influence upon 
the blood. 

In organic diseases of the heart unassociated with pyrexia, and 
in nervous diseases the alkalinity of the blood has been found to 
be increased. In chronic rheumatism, and in renal lesions unac- 
companied by uremic symptoms the reaction of the blood is usu- 
ally found to be unaltered. 



V. SPECIFIC GRAVITY. 

In the majority of healthy male adidts the 
Normal specific gravity of the blood varies from 1055 to 
Range. 1065, the average being in the neighborhood of 
1060. In women the average is somewhat less, 
about 1056; in children it is about 105 1, and in new-born infants 
1066 is considered normal. Diurnal variations in the specific 
gravity have been noted, but these fluctuations are slight and 
unimportant. The blood density of habitual dwellers in high alti- 
tudes is distinctly increased. Venous blood is said to be of slightly 
higher specific gravity than arterial. The average specific gravity 
of the blood of the two sexes, as determined by the principal ob- 
servers, is as follows : 

1 Deut. med. Woch., 1893, vol. xix., p. 10. 

2 Archiv. f. Pathol. Anat., 1889, vol. cxvi., p. 337. 

3 Zeitschr. f. Heilk., 1889, vol. x., p. 106. 

4 Archiv. f. exper. Pathol, u. Pharm., 1898, vol. xli., p. I. 

5 Vratch, 1898, vol. xix., p. 248. Abst., Journ. of Cutan. and Genito-Ur. 
Dis., 1898, vol. xvi., p. 544. 



SPECIFIC GRAVITY. 



99 



Authority. 


Males. 


Females. 


Askanazy, 


1060. 1 


1056.4 


ocnmicii, 


1060 


1050 


Haroroerschlag, 


1 06 1 ^ 

j 


10^7. ^ 


Lloyd Jones, 


io5 8 -5 




Landois, 


io57-5 


IO56 


Becker, 


1057 


IO56.5 


Schmaltz, 


1057 


IO56 


Peiper, 


1055 


i°53 



From a clinical standpoint, the specific gravity 
Pathological of the blood may be regarded, within certain 
Variations, limits, as a tolerably accurate index to the 
corpuscular richness of this tissue, and to the 
hemoglobin equivalent of the erythrocytes, since fluctuations in 
these constituents immediately give rise to corresponding altera- 
tions in the density of the blood-mass. It follows, then, that in 
the various conditions of anemia, characterized by corpuscular 
and hemoglobin losses, low specific gravities are encountered ; 
on the other hand, it is also obvious that in conditions of polycy- 
themia, the cellular increase and the high hemoglobin equivalent 
are mirrored by the corresponding rise in the density of the 
blood. An increase promptly follows any sudden drain upon 
the fluids of the system sufficient to cause inspissation of the 
blood, such as may result from copious diarrhea, free sweating, 
or hyperemesis ; while the density is at once lowered as the re- 
sult of sudden dilution of the blood, following, for example, the 
injection of a large quantity of saline solution, or even the inges- 
tion of a large volume of liquid. Fluctuations in the specific 
gravity of the blood under such circumstances, which are purely 
physiological in character, are invariably of transient duration, 
for the normal relation between the relative volumes of corpuscles 
and plasma becomes quickly reestablished by means of the liquid 
interchange between the tissues and the blood-vessels. 

Owing to the fact that in most instances a close relationship 
exists between the amount of hemoglobin and the specific gravity, 
some investigators are accustomed to take this parallelism as a 
basis for calculating the percentage of hemoglobin in the blood. 
Thus, by determining the specific gravity, and by comparing the 
figure thus obtained with a table giving the hemoglobin equiva- 
lents corresponding to varying degrees of blood density, fairly ac- 
curate results have been obtained. The following hemoglobin 
equivalents of different specific gravities of the blood have been 
determined by Hammerschlag, 1 and by Lichty. 2 

1 Loc. cit. 

2 Phila. Med. Journ., 1898, vol. ii., p. 242. 

LoFC. 



IOO 


THE 


BLOOD 


AS A WHOLE. 






Hammerschlag. 




LlCHTY. 




Specific gravity. 


Hemoglobin equivalent. 


Specific gravity. 


Hemoglobin 


p n 1 j 1 " } n 7 0 ti f 

CU It i t/(lCC rlL , 


t o 1 1 T O 1 C 


2 5-3 0 P er 


cent. 


Tni C T D 1 Pi 

1U OJ AU o° 


2 5 3° 


per cent. 


1< - > 35 AO o° 


3°"35 " 




TAIN T f~\ \ >J 

1030-1043 


30-40 


( i a 


t a-iQ t r\ a r\ 

1U jO — L\JQ\J 


35-4o " 




1043-1045 


40-45 


(( a 


T r~\ A /-> T r~\ A T 

l <JZj.<J — 1<JZJ.K 


4o-45 " 


c e 


IQ 45 IQ 47 


45-5 0 


a a 


I 04 5 — I O48 


45-55 " 


( i 


TOA7-TO/1 fl 

1 Vii / X \~> -L VJ 


5o-55 


d ( ( 


IO48-IO5O 


55-65 " 




1049-1052 


55-65 


1 ( t i 


IO5O-IO53 


65-70 << 




1052-1054 


65-7o 


it i i 


io53- T o55 


7o-75 " 


i i 


1054-1056 


7o-75 


(i l( 


1055-1057 


75-85 " 


i ( 


IO56-IO6O 


75-85 


a ce 


1057-1060 


35-95 " 


i i 


IO6O-IO63 


85-95 


ee u 








IO63-IO65 


95-100 " " 



It will be noted that in both these tables the variations in 
gravity are somewhat greater in high than in low hemoglobin 
percentages. It has been stated by Diabella 1 that, on the aver- 
age, a difference of 10 per cent, in hemoglobin corresponds to 
4.46 parts per thousand in specific gravity : and that differences 
amounting to from 3 to 5 parts per thousand in the specific grav- 
ity may arise from the influence of the stroma of the erythrocytes, 
in blood characterized by a striking disturbance in the parallelism 
which normally exists between these cells and the hemoglobin. 

In the clinical application of this indirect method of computing 
hemoglobin percentages, several conditions, in which factors other 
than the presence of hemoglobin in the erythrocytes influence the 
specific gravity, must be excluded. In leukemia, for example, it 
will be found that hemoglobin percentages based on the above 
tables are much higher than actually exist, the cause of this fal- 
lacy being the presence of enormous numbers of leucocytes in the 
blood ; in pernicious anemia the hemoglobin is frequently higher 
than the specific gravity indicates, for in this disease the individ- 
ual corpuscles are much richer in hemoglobin than normal ; and 
in conditions associated with extensive dropsy the hemoglobin 
percentage does not parallel the specific gravity, owing to the 
abnormally high proportion of fluids in the blood mass. 

These three sources of error, aside from the rather trying tech- 
nique by which one must first determine the specific gravity of 
the blood drop (see page 75), are sufficient to make most work- 
ers reluctant to adopt this method as a substitute for the hemom- 
eter. 

VI. FIBRIN AND COAGULATION. 

The essential factor of coagulation of the blood is the forma- 
tion of fibrin, a proteid substance, produced in the plasma, after 

1 Deut. Archiv. f. klin. Med., 1896, vol. lvii., p. 302. 



FIBRIN AND COAGULATION. 



IOI 



the withdrawal of the blood from the body, by complex chemical 
changes occurring between the soluble calcium salts and the 
nucleo-proteids of the blood, with the consequent production of a 
fibrin ferment. The theories regarding coagulation are numer- 
ous, conflicting, and unsatisfactory, and must necessarily remain 
disputed points until our present uncertain knowledge of the 
chemistry of the blood proteids becomes fuller and more definite. 1 
In the examination of a slide of fresh blood, fibrin appears as 
extremely delicate, straight, filamentous lines which cross and 
recross the field in every direction. It forms a network of fine, 
interlacing, fibrillary bands, in the clear areas of the serum inter- 
vening between the masses of corpuscles, some of the fibrin 



Fig. 33. 




Showing rouleaux formation and fibrin network. 

threads apparently radiating from centers consisting of small 
irregular masses of blood-plaques. The relation of these islands 
of blood-plaques to coagulation and fibrin formation, if, indeed, 
any exists, is undetermined. Petrone 2 considers that the plaques 
inhibit rather than promote these two processes. 

^chafer's "Text Book of Physiology," vol. i., Edinburgh and London, 1898, 
contains a complete exposition of the various theories of coagulation of the blood exist- 
ing up to the present time. 

2 Morgagni, 1897 ; n. 5 and 6. 



102 THE BLOOD AS A WHOLE. 

In normal blood the formation of the fibrin 
Hyperinosis network becomes apparent within two or three 
and minutes after exposure of the blood to the air, 
Hypinosis. and the process is completed within seven or 
eight minutes. In certain pathological condi- 
tions, however, both the length of time required for its formation 
and the density of the network varies. An increase in the 
amount of the fibrin network is spoken of as hyperinosis, while a 
decrease in fibrin is termed hypinosis. 

In general terms, it may be stated that fibrin 
Pathological is increased in acute inflammatory and infectious 
Variations, diseases, especially in those attended by an ac- 
tive febrile movement and by exudative proc- 
esses, the amount of fibrin roughly corresponding to the intensity 
of the process. This statement is made with certain reserva- 
tions, for the rule does not hold true in all such instances, as is 
noted below. All febrile states do not, however, imply a fibrin- 
increase, for none is found in the fevers associated with grave 
cases of chlorosis and of pernicious anemia. Hayem 1 suggests 



Fig. 34. 




Hyperinosis. 

Showing marked increase in the tensity of fibrin network. 



that the density of the fibrin network may be taken as an indica- 
tion of the individual's resisting powers against disease, inasmuch 
as it appears to be more marked in the blood of the vigorous than 

1 << Du Sang," etc. Paris, 1889. 



OLIGEMIA. 



IO3 



of the feeble. In acute inflammations, accompanied by serous 
and purulent exudates, a dense fibrin reticulum is observed, the 
extent of the exudation being in a degree measured by the 
density of the network. Fibrin is increased to a slighter extent 
in parenchymatous inflammations, in inflammations of the 
mucous membranes and skin, and in the febrile stages of chronic 
suppurations. Among the diseases which are associated with an 
increase in fibrin are the following : abscess, pneumonia, rheumatic 
fever, erysipelas, acute gout, severe angina, bronchitis, influenza, 
diphtheria, pleurisy, peritonitis, pericarditis, hepatitis, meningitis, 
acute gastritis, enteritis, cystitis, vaginitis, pustular stage of variola, 
and supptirathig tuberculous cavities. Fibrin is not increased 
in malignant neoplasms, enteric fever, malarial fever, tuber- 
culosis ^ pernicious anemia, leukemia, chlorosis ^ and purpura. In 
parencliymatous nephritis it is but slightly increased, if at all, 
while in interstitial nephritis the increase may be notable. 

Pfeiffehr 1 declares, as the result of his investigations, that in 
all diseases in which an increase of fibrin exists inflammatory 
leucocytosis is also present, and that he has never been able to 
demonstrate hyperinosis without coexisting increase in the number 
of leucocytes. But leucocytosis does not invariably imply hyper- 
inosis, although the two conditions almost always go hand in 
hand, for leucocytosis may occur in malignant disease unattended 
by fibrin increase ; on the other hand, in influenza the fibrin net- 
work is denser than normal, while the number of leucocytes is 
not increased. 

VII. OLIGEMIA. 

The term oligemia signifies a reduction in the total volume of 
the blood, involving a diminution of both the liquid and the cel- 
lular portions. It occurs most conspicuously after hemorrhage, 
and probably after this accident only. Sometimes the hemorrhage 
having been profuse, the oligemia proves rapidly fatal ; but in 
other instances, where the hemorrhage has been less extensive, 
the decreased volume of blood is slowly made up, first by a rapid 
osmosis of serum into the depleted capillaries from the neighbor- 
ing lymph spaces, and later by a slower numerical increase of 
the cellular elements, the products of an actual manufacture of 
erythrocytes by the blood-making organs. 

In some of the advanced cachectic states, in which profound 
adynamia and poor nourishment of the body are prominent clin- 
ical manifestations, there is seemingly good reason for believing 
in the existence of a true oligemia ; but in the absence of con- 

1 Zeitschr. f. klin. Med., 1897, vol. xxxiii., p. 215. 



104 



THE BLOOD AS A WHOLE. 



firmatory evidence, reduction of the blood-volume in this class of 
cases must remain rather a suspicion than an accepted fact. The 
term oligemia is, therefore, in the light of our present understand- 
ing, applicable only to blood losses resulting from hemorrhage. 

VIII. PLETHORA. 

The term plethora is currently used to express a condition 
characterized by an actual excess in the total volume of the blood, 
affecting both the liquid and the cellular elements. According 
to the views of many of the older and a few of the modern path- 
ologists, a true polyemia, or an increase in the blood volume, un- 
accompanied by any qualitative changes, is thought to exist in 
certain individuals whose mode of life and luxurious habits are 
supposed to predispose and give rise to excessive blood-forma- 
tion. The compatibility between a real full-bloodedness and 
a "high-liver" was formerly much more generally credited than 
at the present time, and the association of such signs as a rich, 
ruddy complexion, enlargement of the superficial blood-vessels, 
and a full, bounding pulse was depended upon for the recognition 
of this condition. Of late, however, the drift of opinion is against 
the probability of any such permanent increase in blood volume, 
but until an accurate method of estimating the total quantity of 
blood in the body has been devised, the presence or absence of a 
real plethora must obviously remain conjectural. 

True plethora may occur as a transitoiy condition, as the re- 
sult of the direct transfusion of blood, or the mechanical forcing 
back into the general circulation of a quantity of blood from a 
part to be removed from the body, as by the use of an Esmarch 
rubber bandage previous to the amputation of a limb ; in a similar 
manner, a new-born infant may become temporarily plethoric by 
a complete emptying of the placenta before tying the umbilical 
cord. Plethora resulting from any of these influences is invari- 
ably of a transient character, for the physiological balance of the 
organism rapidly disposes of the surplus amount of blood, by de- 
struction of the excess amount of cellular elements and by the 
elimination of the liquid portions. 

Serous plethora may be defined as an increase in the volume of 
blood due to excessive quantities of its liquid and saline con- 
stituents, without augmentation in the number of its cellular 
elements. A condition of this sort may be dependent upon the 
ingestion of large amounts of liquids, upon the transfusion of saline 
solutions, or upon vaso-motor dilatation, whereby the transfer 
of an unduly large amount of liquids from the tissues to the blood- 



HYDREMIA. 



105 



vessels is promoted, In organic lesions of the kidneys and of the 
heart, with diminished elimination of water from the system, a 
serous plethora of more or less chronicity may develop. The 
condition, however, is usually of transient duration, as the surplus 
liquids in the circulator}- system are quickly disposed of, and the 
blood volume reduced to normal, by intracapillary transudation. 

Cellular Plethora is a term which may appropriate!}* be applied 
to the condition also known as polycythemia, consisting in an in- 
crease in excess of the normal standard in the number of erythro- 
cytes. The circumstances under which this change occurs will 
be discussed later. (See page 149.) 

IX. HYDREMIA. 

A relative increase in the quantity- of liquid constituents of the 
blood is known as hydremia. This condition must not be con- 
fused with serous plethora, which is characterized by both a 
relative and absolute increase in the liquids of the blood. The 
specific gravity- of the blood is observed to fall in relation to the 
degree to which the change develops. 

Hydremia may be produced by an}- factors which disturb the 
normal relations between the cellular and the liquid elements of 
the blood, so that the latter are unduly increased. In other 
words, the blood is diluted, in consequence of which a given drop 
of such blood shows an apparent decrease in the number of cel- 
lular elements, although the latter are in reality unaffected by the 
change. Hydremia is observed after extensive hemorrhages i in 
which the primary effect of the oligemia is the taking up by the 
capillaries of an excess of tissue-fluids, to replace the blood loss : 
later, as blood-formation gradually makes up for the cellular 
deficiency, the normal ratio between the corpuscles and the plasma 
is reestablished. Hydremia ma}- also occur as the result of the 
ingestion of large amounts of liquids, after the injection of normal 
saline solution, and as a consequence of vaso-motor dilatation. 
The water}- constituents of the blood are relatively increased in 
certain of the severe anemias i owing to the deficiency of corpus- 
cular elements, which is compensated by fluids derived from the 
tissues. In some dropsical conditions, notably those associated 
with renal and cardiac lesions, hydremia may also be said to exist, 
either with or without anemia. Hydremia, while it does not 
necessarily imply the coexistence of anemia, is naturally often an 
accompaniment of the latter condition. 

Hydremia dependent upon such physiological factors as inges- 
tion of fluids and vaso-motor dilatation is a transient condition, for 



io6 



THE BLOOD AS A WHOLE. 



the excess amount of fluid is promptly eliminated, and the normal 
relations restored. In other conditions the duration of the change 
obviously depends upon the nature and permanency of the etiolog- 
ical factor or factors. 

X. ANHYDREMIA. 

Anhydremia is a condition in which a relative diminution in 
the liquid constituents of the blood occurs, as the result of rapid 
osmosis from the capillaries into the surrounding tissue. Inas- 
much as the cellular elements do not share in this draining-away, 
their number is necessarily increased in a given drop of such con- 
centrated blood. The specific gravity of the blood increases in 
relation to the severity of the fluid drain. 

Conditions which cause the sudden dissipation of large quanti- 
ties of liquids from the body, in consequence of hyperactivity of 
the mucous and serous surfaces, are the most prominent factors 
in producing anhydremia. Thus, after profuse diarrheas, urinary 
crises, free sweating, excessive vomiting, and sudden and exten- 
sive pleural and peritoneal effusions the blood becomes concen- 
trated from a temporary loss of its fluid elements, which pass 
from the vessels into the tissues to replace the liquids lost in 
consequence of the drain. 

Oliver 1 has shown also that a moderate degree of anhydremia 
may arise as the result of various influences which cause an in- 
crease in arterial tension, and a consequent acceleration in the 
transfer of water from the vessels into the tissues. For example, 
the change has been brought about by the influence of local and 
general exercise, faradism, massage, cold bathing, and the admin- 
istration of supra-renal extract. 

From the nature of the drain, which is rapidly compensated by 
the constant interchange which goes on between the vessel- and 
the tissue-fluids, anhydremia is a temporary condition. A per- 
fect physiological balance limits its duration to brief periods of 
time. (See " Polycythemia," p. 149.) 

XL LIPEMIA. 

Fat is present in normal blood, in the form of an exceedingly 
fine emulsion, the amount varying in man from 1.00 to 3.25 parts 
per 1,000 of blood, the mean amount being 1.6, according to the 
analyses of Becquerel and Rodier. 2 

1 Croonian Lectures, Lancet, 1896, vol. i., pp. 1541, 1621, 1699 and 1778. 
2 Cited by Futcher: Journ. Am. Med. Assn., 1899, vol. xxxiii., p. 1006. 



MELANEMIA. 



10/ 



By the term lipemia is meant the presence of an excess of free 
fat in the circulating blood, a phenomenon which is observed in a 
number of conditions, both physiological and pathological. Thus, 
the blood may contain a sufficient amount of fat to give rise to 
temporal-}' lipemia during the period of digestion, especially after 
a meal rich in fats ; the condition may be also met with in the 
breast-fed infant, in the pregnant woman, and in the obese. 
Me?istrual suppressio7i may also give rise to a similar excess of 
fat in the blood. 

The existence of lipemia is of little clinical importance, for it 
has been observed in a number of diseases, so that it cannot be 
considered characteristic of any particular lesion. It has been 
noted in the following conditions : chronic alcoholism, diabetes 
mellitus, certain diseases of the liver, heart, and pancreas, chronic 
nephritis, splenitis, tuberculosis, malarial fever, typhus fever, Asiatic 
cholera, and poisoning by pJwsphorus and by carbon monoxide. 
Lipemia commonly occurs as the result of lacerated wounds of the 
blood-vessels situated in fatty tissues, and after fractures of the 
long bones involving injury of the fatty marrow. 

The degree of lipemia may be so marked that the macroscop- 
ical appearance of the fresh blood is altered, the presence of large 
quantities of free fat rendering it turbid and milky. This is es- 
pecially conspicuous in the specimen of blood-serum obtained by 
centrifugalization, which has a distinct grayish, opaque appear- 
ance, not unlike chyle. 

Macroscopically, the presence of lipemia may be determined 
by mixing with ether in a test-tube a portion of the turbid blood- 
serum, the excess of fat promptly dissolving, so that the serum 
becomes clear. 

Microscopically, lipemia may be recognized by the presence 
of large numbers of glistening fat-droplets, about .5 to 2 ^ in di- 
ameter, which lie free in the plasma between the groups of cor- 
puscles, often exhibiting very lively Brownian movements. These 
droplets respond to the usual tests for fat, dissolving in ether, 
and staining black with osmic acid, and brick-red with Sudan III. 

XII. MELANEMIA. 

The occurrence in the circulating blood of minute particles of 
melanin or pigment, derived usually from the hemoglobin of the 
red blood corpuscles destroyed by blood parasites, is known as 
melanemia. These melanin particles appear as fine bits of granu- 
lar matter, of a reddish-yellow or black color, either lying free in 
the blood-plasma, or embedded in the protoplasm of the leuco- 



io8 



THE BLOOD AS A WHOLE. 



cytes. In some instances the granules are extremely small-sized 
and few in number, and again the amount may be considerable, 
numbers of pigment particles being apparently fused into masses. 

Melanemia is frequently present in malarial fever, especially 
of the severer types, both in the form of free pigment, and as 
pigmented leucocytes. Particles of pigment in the bodies of the 
leucocytes have also been seen in relapsing fever, in melanotic 
sarcoma, and in Addison 's disease. 

XIII. GLYCEMIA. 

Glycemia, or the presence in the blood of grape-sugar, occurs 
in perfectly normal blood to a very slight degree, the quantity of 
sugar found under physiological circumstances not exceeding 1.5 
parts per thousand. The presence of sugar in excess of this fig- 
ure, which may be termed hyperglycemia, is met with in diabetes 
mellitus, in which disease as high as 9 parts per thousand have 
been detected. 1 The investigations of Freund 2 and of Trinkler 3 
apparently show that the blood in carcinoma, especially of vis- 
ceral involvement, contains an excess of some reducing agent, to 
all intents and purposes identical with sugar. The former author, 
in consequence of this fact, lays stress on the finding as a means 
of differentiating between carcinoma and sarcoma, since no such 
increase has been observed as an accompaniment of the latter 
type of neoplasm. 

The most accurate method of detecting small quantities of 
sugar in the blood is by the phenyl-hydrazin hydrochloride 
test, conducted by von Jaksch 4 as follows : — A small amount of 
blood, obtained by wet-cupping, is first freed from proteids, by 
adding an equivalent weight of sodium sulphate, and then boil- 
ing, and filtering, the filtrate thus obtained being used for the 
test. A solution is now made in a test-tube, by mixing 2 
parts of phenyl-hydrazin hydrochloride and 4 parts of sodium 
acetate with about 6 cubic centimeters of water, and gently 
heating the fluid, if necessary, to effect solution. Five cubic 
centimeters of the proteid-free filtrate, while still warm, are 
added to an equal volume of the test-solution. This mixture is 
then placed in a test-tube half filled with water, heated for half 
an hour in a water-bath, and allowed to stand until cool. When 
cooling of the mixture has occurred, it shows under the micro- 

1 Hoppe-Seyler : Virchow's Archiv., 1858, vol. xiii., p. 104. 
2 Wien. med. Blatter, 1885, vol. viii., pp. 268 and 873. 
3 Centralbl. f. d. med. Wissensch., 1890, vol. xxviii., p. 498. 
4 Zeitschr. f. klin. Med., 1886, vol. xi., p. 20. 



URICACIDEMIA. 



109 



scope the presence of the characteristic yellowish crystals of 
phenyl-glucosazon, either detached or in clusters, together with 
colorless crystals of sodium sulphate. 

XIV. URICACIDEMIA. 

The presence in the blood of a demonstrable amount of uric 
acid has been designated as uric acidemia. The blood of the 
normal individual does not contain this substance in amounts 
sufficiently large to be detected by ordinary clinical tests, but it is 
found in appreciable quantities in a number of pathological condi- 
tions. Garrod 1 many years ago recognized that excessive accumu- 
lation of uric acid in the blood was associated with gout, and he at- 
tached to this sign much diagnostic significance. Later investiga- 
tions, however, have proved the utter unreliability of this finding 
as a pathognomonic sign of this disease, for in recent years a large 
number of other conditions have been found to be more or less 
constantly accompanied by relatively large amounts of uric acid 
in the circulating blood. Notable examples of such diseases are 
pneumonia, hepatic cirrhosis, acute and chronic nephritis, chronic 
gastritis, leukemia, severe anemia, and those conditions in which 
deficient blood aeration constitutes a prominent clinical symptom, 
such as organic cardiac disease, exudative pleurisy, and emphysema. 
Uric acid is not found in the blood in enteric fever, and in rheu- 
matic fever. Pyrexia, of itself, evidently has no influence in pro- 
ducing uricacidemia, nor is it at all probable that this condition 
goes hand in hand with an excessive elimination of uric acid in 
the urine. 

Garrod's test is well adapted clinically for detecting the pres- 
ence of appreciable quantities of uric acid in the blood. Slightly 
modified, it may be applied in the following manner : — Two and 
one-half cubic centimeters of blood-serum, obtained by blistering, 
are placed in a shallow watch glass, and acidulated by the addi- 
tion of about 4 drops of a 30 per cent, aqueous solution of acetic 
acid. A linen thread is then immersed in the acidulated blood, 
which is slowly evaporated at a temperature not exceeding 70 0 
F. At the expiration of from twenty-four to forty-eight hours, 
if the sample of blood contains uric acid, characteristic crystals 
of this substance are deposited upon the thread, their identity 
being readily detected by microscopical examination, and by the 
murexide test. 

1 Med. and Chirurg. Trans., 1854, vol. xxxvii., p. 49. Also, Ibid., 1848, vol. 
xxxi., p. 183. 



I 10 



THE BLOOD AS A WHOLE. 



XV. CHOLEMIA. 

The presence in the blood of bile or bile-pigments has been 
termed cholemia, a condition which accompanies various forms 
of icterus. Bilious blood may have, as already stated, a yellow- 
ish-red color, and may yield on agitation an abundant foam, tinged 
with yellow. Bilirubin may be detected in the blood even when 
urine tests for this substance have proved negative, according to 
von Jaksch, 1 who employs this procedure to demonstrate its pres- 
ence : — About 10 cubic centimeters of blood, obtained by wet- 
cupping, are allowed to clot, after which the serum is pipetted 
off, filtered through asbestos, and coagulated at a temperature of 
8o° C. Thus treated, the presence of bilirubin is betrayed by a 
greenish discoloration of the serum, which, if bile-free, remains a 
pale straw color. Should a brownish color develop by this test, 
the presence of hemoglobin in the serum is indicated. 

XVI. ACETONEMIA AND LIPACIDEMIA. 

The occurrence in the blood of demonstrable amounts of ace- 
tone and of fatty acids are referred to as acetonemia and lipaci- 
demia, respectively. Acetonemia has been found in associa- 
tion with numerous pathological conditions, chiefly in those 
characterized by pyrexia, while fatty acids in the blood have been 
detected in diabetic coma, in malignant jaundice, in leukemia, 
and in various acute infections. 

For the recognition of acetone Simon 2 recommends Den- 
nige's test, to be applied as follows : — About 3 cubic centimeters 
of blood are treated with 30 cubic centimeters of Dennige's 
reagent ( 20 grammes of concentrated sulphuric acid mixed with 
100 cubic centimeters of distilled water, to which 5 grammes 
of yellow oxide of mercury are then added), and allowed to stand 
until a dark brown precipitate has formed, after which the 
supernatant fluid is filtered off, and treated with more of the 
reagent, so as to effect complete precipitation. It is then acidi- 
fied by the addition of about 3 cubic centimeters of a 30 per 
cent, solution of sulphuric acid, and boiled for one or two min- 
utes. The appearance of a white precipitate on boiling indicates 
the presence of acetone. This precipitate may be almost wholly 
dissolved by the addition of hydrochloric acid in excess. 

Fatty acids may be detected by boiling equal parts, by weight, 
of blood and sodium sulphate, filtering, evaporating the filtrate 

1 Loc. cit. 

2 ''Clinical Diagnosis," Phila., 1901 (3d ed. ). 



BACTERIEMIA. 



I I I 



to dryness, and then extracting the residue with absolute alcohol. 
Microscopical examination of the residue will reveal crystals of 
fatty acids, if lipacidemia exists. 

XVII. BACTERIEMIA. 

Bacteriemia, or the presence of bacteria in the 
Occurrence, circulating blood, is a condition associated with 
a number of infectious diseases, in which instances 
it is frequently, but by no means constantly, possible to dis- 
cover the specific micro-organism of the disease in question by 
careful bacteriological examination of the blood. The demonstra- 
tion in the blood, even if it is possible only in occasional instances, 
of such bacteria as pyogenic cocci and pnenmococci in septic dis- 
eases, of the streptococcus pyogenes and other pyogenic organisms 
in malignant endocarditis, of the bacillus of Eberth in enteric 
fever, of the gonococcus in gonorrheal rheumatism, and of the 
bacillus tuberculosis in severe cases of acute miliary tuberculosis, 
is sufficient proof, without citing other instances, of the diag- 
nostic value of bacteriological blood examinations, which are 
warranted in every case of severe infection the nature of which 
appears doubtful. 

From the clinician's viewpoint, normal blood 
Latent is absolutely sterile, since no cultural method has 
Infection, yet been devised by which it is possible to demon- 
strate the presence of bacteria in the circulation 
of the healthy individual. From the pathologist's standpoint, 
however, such a statement must be guardedly accepted, in the 
light of recent investigations. Adami, 1 in a recent brilliant resume 
of the whole field of bacterial infection, cites a series of apparently 
conclusive experiments by his assistants, Nicholls and Ford, who 
found that the kidneys and livers of healthy animals, removed 
aseptically immediately after death and placed in agar-agar kept 
at the temperature of the body, showed after a few days a rela- 
tively abundant growth of bacteria. This observer concludes 
that under normal conditions the leucocytes pass out through 
the mucosa on to the free surface of, more especially, the alimen- 
tary tract, some of these cells then undergoing destruction, while 
others, now laden with various foreign matter, including bacteria, 
pass back again into the submucosa and find their way either 
into the lymphatic channels or into the portal venules. In both 
of these sites there exists a decided tendency toward bacterial 
disintegration and destruction. Such isolated bacteria as may 

1 Jour. Am. Med. Assn., 1899, vol. xxxiii., pp. 1509 and 1572. 



I 12 



THE BLOOD AS A WHOLE. 



have escaped leucocytal destruction or removal by the lymphatic 
glands or by the endothelium of the portal system, may pass 
either through the thoracic duct or through the liver, and enter 
the systemic circulation, from which they are eliminated chiefly 
by the kidneys. Such a condition as this, known as " latent in- 
fection " or ''latent microbism," appears to be compatible with 
perfect health, for the number of bacteria which thus gain access 
to the blood-stream and tissues is so small that unless their 
virulence is especially striking and the susceptibility of the indi- 
vidual peculiarly marked, the resisting powers of the . tissues re- 
main sufficiently strong to prevent bacterial proliferation. It is 
also obvious that the presence in the blood of such a limited 
number of bacteria cannot be demonstrated by culturing. 

If, on the other hand, the conditions are such 
Blood that bacteria multiply in the blood to any decided 

Cultures, extent, then their development in artificial media 
outside the body may be successfully obtained in 
many instances, provided that proper technique is employed. 
That this has not been more successfully accomplished is no 
doubt due to the powerful bactericidal action of the shed blood, 
whereas this influence in the circulating blood is but trifling. As 
Adami remarks, " Because certain observers have failed to dis- 
cover bacteria in the blood from cases of infectious diseases, it by 
no means follows that the blood when shed has been free from 
bacteria." Therefore, it seems fair to presume that if precautions 
are taken to attenuate the bactericidal properties of the shed 
blood, by freely diluting it with a large quantity of fluid media, 
instead of using relatively small amounts of solid culture, as has 
been done largely in the past, blood culturing will yield a much 
higher percentage of positive findings, and will give more uniform 
results. (See " Bacteriological Examination," page 83.) 

Among the various bacteria which different 
Bacteria observers have succeeded in isolating from the 
Found in circulating blood are included many micro-organ- 

the Blood, isms, the identity of which as etiological factors 
of disease is generally recognized, and also a 
number to which pathogenicity cannot be convincingly attributed. 
The following list gives the most important examples of the 
former class : 

B. a?ithracis. 

B. coli communis. 

B. influenzce. 

B. leprce. 

B. mallei. 



ANEMIA. 



113 



B. pestis bubo niece. 
B. tetani. 
B. tuberculosis. 
B. typhosus. 

Diplococcus intracellularis meningitidis. 

Gonococcus. 

Pneumococcus. 

Pyogenic staphylococci. 

Pyogenic streptococci. 

In addition to this list, a certain amount of interest attaches to 
the discovery in the blood of certain bacilli (Achalme), and diplo- 
a?<rr2 (Triboulet) in rheumatic fever ; of peculiar bacilli (Afanassiew) 
in relapsing fever, in addition to the specific spirillum of this in- 
fection ; of diplobacilli (Craig) in mumps ; and of diplococci (Class) in 
scarlet fever, and in typhus fever (Balfour and Potter). The exact 
significance of finding the bacillus icteroides (Sanarelli) in the blood 
of yellow fever patients is still a current topic of discussion. 

The conditions in which the above-named bacteria occur in the 
blood will be discussed in a later section, under the diseases in 
question. (See " General Hematology.") 

XVIII. ANEMIA. 

In a clinical sense, the term anemia refers to 
Definition, any deterioration in the quality of the blood, af- 
fecting either the erythrocytes, the hemoglobin, 
or both of these elements. Thus, in pernicious anemia the most 
conspicuous deterioration in the quality of the blood is a diminu- 
tion in the number of erythrocytes, or an oligocythemia; in 
chlorosis, the most marked change is usually a loss of hemo- 
globin, or an oligochromemia ; while in many other anemic con- 
ditions the erythrocytes and hemoglobin are decreased more or 
less proportionately. While it is true that, strictly speaking, 
the word anemia may also be used to designate a reduction in 
the blood volume, this condition is better defined by the use of 
the term oligemia. Ischemia is a form of local anemia resulting 
from some mechanical interference with the blood supply of the 
affected area. 

In certain individuals with such decided pallor 
Pseudo- of the skin and mucous membranes that their 
Anemia. appearance at once leads one to infer that they 
are suffering from a well-defined anemia, no signs 
of this condition can be discovered, for even after the most careful 
examination of the blood, the number of erythrocytes and the per- 
8 



H4 



THE BLOOD AS A WHOLE. 



centage of hemoglobin may be found to be normal. Such instances 
of apparent blood deterioration have been called pseudo-anemia ; 
they are often explained by hereditary peculiarities, by vaso- 
motor disturbances affecting the superficial capillaries, and by 
deficiencies in the pigment and in the development of the capillary 
network of the skin. Dwellers in tropical countries are especially 
prone to this spurious form of anemia, to which the misnomer tropi- 
cal anemia is occasionally applied. Every medical clinic can furnish 
patients suffering from neurasthenia, tuberculosis, and advanced 
Bright' s disease, whose pallid countenances are a striking con- 
trast to their normal blood-counts. It does not follow, there- 
fore, that pallor of the skin and mucous membranes is invariably 
an indication of anemia, although this sign is not misleading 
in the majority of instances. On the other hand, it should not 
be forgotten that persons of good color and robust appearance 
sometimes suffer from decided anemias without the fact becoming 
evident at first glance. In view of these sources of error, in 
order to diagnose anemia with absolute accuracy, an examination 
of the blood is essential, for no matter how valuable other 
clinical signs may appear, the changes in the blood are often the 
real key to the situation. 

An entirely satisfactory classification of the 
Classifi- various forms of anemia still remains to be de- 
cation. vised, in spite of the numerous attempts which not 
a few eminent authorities have made to group these 
conditions according to sound pathological considerations. There- 
fore, largely for the sake of convenience, all anemias may be broadly 
grouped into two theoretical classes : primary and secondary. 

According to this tentative classification, primary anemias may 
be considered those in which a lesion of the hematopoietic organs 
is essentially accountable for the production of the disease. In 
anemias of this sort, the etiological factors are either entirely 
undiscoverable, or, if they are to be detected, too trivial to explain 
the intensity of the disease. Here the predominant clinical 
manifestations are to be found in the changes occurring in the 
composition of the blood, the other symptoms being considered 
secondary to, and dependent upon, these alterations. 

Under the term secondary ane7nia are included those cases 
of anemia which are apparently secondary to, and symp- 
tomatic of, certain definite pathological lesions not primarily 
affecting the blood-making organs, such as, for example, enteric 
fever, syphilis, tuberculosis, malignant disease, malarial fever, and 
hemorrhage. In such anemias the other clinical symptoms are, 
as a rule, much more conspicuous than the blood-changes, which 



ANEMIA. 



115 



are thought to be secondary. An exception to this general rule 
must be taken, however, in regard to the anemia caused by the 
presence of the bothriocephalus latus in the intestinal canal, for 
in this infection the blood-picture is by all odds the most striking 
clinical manifestation. It is, furthermore, true that in some 
instances a secondary anemia may apparently merge into one of 
the primary type, should the protracted duration of the former 
in course of time cause such profound systemic effects that finally 
the blood-making organs become exhausted, and refuse ade- 
quately to supply the constant demand for corpuscles, with the 
result that the most prominent clinical signs now are found in 
the blood, and not in the original symptoms of the disease in 
question. The high-grade anemia which sometimes follows 
enteric fever, becoming of such intensity that it counterfeits a 
primary anemia, may be cited as an example of this change. 

Until further progress has been made in the study of the phys- 
iology and pathology of the blood-making organs, the following 
provisional classification of the anemias may be used for clinical 
purposes : — 

I. Primary Anemia. Chlorosis, pernicious anemia, splenic anemia, 
lymphatic leukemia, spleno-medullary leukemia, Hodgkin's disease. 

II. Secondary Anemia. Dependent upon causes such as 
hemorrhage, intestinal parasites, prolonged lactation, unfavorable 
hygiene, metal poisoning, malignant disease, acute infections, and 
chronic diseases producing long-standing drains on the albumi- 
noids of the blood. 

Excluding the effects of hemorrhage, deficient 
Pathogenesis, blood formation, excessive blood destruction, and 
a combination of these two processes are generally 
regarded as the three possible essential factors in the production 
of anemia. Deficient hemogenesis is to be attributed to a large 
number of different causes, among the most prominent of which 
may be mentioned the influence of unhygienic surroundings, 
and insufficient nourishment from improper food and from 
inadequate powers of assimilation. It is also probable that con- 
genital and acquired failure of the blood-making organs, and the 
presence of growths which intercept the material for blood forma- 
tion are to be considered as the origin of defective hemogenesis in 
some instances. 1 Excessive blood destruction may be due to 
acute febrile and infectious conditions, or to the presence in the 
blood of certain toxines which destroy the corpuscles. It is 
characterized during life by an excess of urobilin and iron in 
the urine, and by the development of hematogenous jaundice. 

1 Mackenzie : Lancet, 1891, vol. i., p. 73. 



SECTION III. 



HEMOGLOBIN, ERYTHROCYTES, BLOOD PLAQUES, 
AND HEMOCONIA. 



( Triacid Stain. ) 

Fig. 1. Normal Erythrocytes. 

Fig. 2. Erythroblasts. 

r. Microblast. Note the dense, glistening nucleus, and the scanty, ragged zone of proto- 
plasm. 

2, 3, 4, 5, 6. Normoblasts. The process of partial nuclear extrusion is apparently shown 
in 3 and 5; in the latter cell the basic affinity of the nucleus is singularly slight. The 
cell, 6, while as large as many megaloblasts, retains the nuclear characteristics of the 
normoblast, of which it represents perhaps a hydropic form. Some writers regard 
such erythroblasts as megaloblasts, on account of their large size. 

7, 8, 9, 10, 11, 12, 13. Megaloblasts. In 7 the nucleus, while normoblastic in size, is 
megaloblastic in structure and in staining affinity. Note the variation in the size of 
these cells, their delicate nuclear chromatin, and their decided tendency toward 
polychromatophilia. In all the nucleus and protoplasm are separated by a conspicu- 
ous hyaline ring. 

Fig. 3. Erythroblasts with Multiple Nuclei. 

1. Cell with a constricted, convoluted nucleus, apparently undergoing solution in the 

protoplasm. 

2. Normoblast with three nuclei arranged somewhat in the form of a clover-leaf. 

3. Cell with two large nuclei, each apparently in an early stage of extrusion. Note the 

affinity for fuchsin displayed by the protoplasm and by the upper nucleus, and the 
distinct hyaline zone encircling the lower one. 

4. 5. Normoblasts in karyokinesis. 

Fig. 4. Erythrocytes Deformed in Shape and Size. 

1, 2. Microcytes. 

3. Megalocyte. 

4, 5, 6, 7, 8, 9, 10, 11, 12, 13. Poikilocytes. Many of these cells are highly polychromalo- 

philic, especially 11, 12, and 13. 

(Eosin and Methylene-blue .) 

Fig. 5. Erythrocytes Showing Degenerative Stroma Changes. 

Granular basophilia is shown by 1 and 2 ; extreme decolorization by 3, 4, and 5. The other 
cells represent various stages of hemoglobin loss and protoplasmic degeneration. 



Note. — Plates I, II, III, IV, and V are all drawn on the same scale, a Leitz ts-inch oil- 
immersion objective and 4 ocular, with a Zeiss camera-lucida, being used. 



10 



9 



3 

12 




8 



1 



Fig. 5. 

The Erythrocytes. 
(Figs, i, 2, 3, and 4, Triacid Stain; Fig. 5, Eosin and Methylene-blue .) 
(E. F. Faber,/^c.) 



SECTION III. 



HEMOGLOBIN, ERYTHROCYTES, BLOOD PLAQUES, 
AND HEMOCONTA. 



I. HEMOGLOBIN. 

Hemoglobin, which occurs in the circulating 
General blood in chemical union with oxygen as oxyheni- 

Properties. oglobin, is an extremely complex ferruginous and 
albuminoid substance contained within the stroma 
of the erythrocytes. It constitutes approximately nine-tenths of 
the latter' s total bulk, and a trifle less than fourteen per cent, of 
the whole blood. Hemoglobin displays a striking avidity for 
combining with oxygen to form a peculiarly unstable, but defi- 
nite, chemical compound, and a similar facility for yielding up to 
the tissues much of its oxygen, during its passage through the 
capillary circulation. Under the influence of deoxidizing agents, 
oxyhemoglobin may be deprived of its loosely combined oxygen 
molecule, the resulting oxygen-free constituent being known as 
reduced hemoglobin. Rhombic crystals of oxyhemoglobin, scarlet 
or reddish-green in color, are rapidly formed if, for any reason, 
separation of this substance from the corpuscular stroma takes 
place. Methemoglobin is an oxygen compound of hemoglobin 
containing the same quantity of combined oxygen as the latter, 
but differing from it in holding its oxygen constituent in a more 
intimate union. The dingy brown color which develops in a so- 
lution of oxyhemoglobin after prolonged exposure to the atmos- 
phere, evidences the production of this variety of blood-pigment. 
(See " Methemoglobinemia," page 124.) 

The amount of iron (in the form of hemochromogeri) which 
hemoglobin contains is considerable — somewhat in excess of 
four per cent. It has been shown, clinically, by estimates made 
with the ferrometer and the hemometer, that no fixed parallelism 
is maintained between the percentage of hemoglobin and the iron 
contained in the blood. 1 

Under the action of acids, strong alkalies, or heat, hemoglobin 
may be readily decomposed into two constituents : hematin, or 
an iron-containing principle ; and an albuminous residue of un- 
known character, but somewhat resembling globidin. In combi- 

1 Rosin and Jellinek : Zeitschr. f. klin. Med., 1900, vol. xxxix., p. 109. 



120 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 

nation with hydrochloric acid hematin forms a crystalline hydro- 
chloride of hematin, termed hemin, or TeichmantCs crystals. 
Under the microscope these crystals appear as black or dark 
brown, elongated rhombic prisms belonging to the triclinic sys- 
tem, which are insoluble in water, alcohol, ether, chloroform, 
and dilute acids. They may be demonstrated by preparing a 
slide of blood (or of any dried substance containing blood-pig- 
ment) to which a small quantity of common salt has been added; 
a drop of glacial acetic acid is then run beneath the cover-glass 
so that it mixes with the blood and salt, and the specimen thus 
prepared is heated to just below the boiling point over a Bunsen 
flame. On cooling, Teichmann's crystals may be seen under the 
microscope with a low-power dry objective. 

Iron-free hematin, or hematoporphyrin, may be derived from 
blood by the admixture of concentrated sulphuric acid. This 
substance is closely related chemically to urobilin, and occurs oc- 
casionally as a pigment in nature and in normal and pathological 
urines. Hematoidin, which also is free from iron, occurs in the 
form of reddish rhombohedral crystals, only in old clots resulting 
from blood extravasations, such as cerebral hemorrhages, and 
splenic infarcts. It is derived from hematin, and is probably 
identical with bilirubin. 

The chief source of hemoglobin is the iron 
Origin. contained in various food products, about ten 
milligrammes daily representing the amount of 
this metal ingested in an ordinary diet, according to the analyses 
of Stockman. 1 In event of a stoppage of this source of an iron 
supply, the formation of hemoglobin may proceed from the 
supply of iron stored up in various organs of the body, notably 
in the liver. Bunge 2 has shown that in the young infant, whose 
natural food, milk, contains but a slight trace of iron, this source 
of hemoglobin manufacture is most potent. 

The recent experiments of Aporti 3 regarding the origin of 
hemoglobin and the erythrocytes have shown that animals sub- 
jected to repeated bleedings and kept on an iron-free diet, are able 
up to a certain point to utilize the supply of body iron for hemo- 
globin manufacture ; but that when such a demand became so 
severe that this supply was exhausted, the red corpuscles became 
progressively paler and paler, and the animal finally died. During 
the course of these experiments, if the animal received injections 
of iron, a prompt and striking increase in hemoglobin occurred, 

1 Journ. of Physiol., 1897, vol. xxi., p. 55 ; 1895, vol. xviii., p. 484. 
2 Zeitschr. f. physiol. Chem., 1892, vol. xvi.,p. 177. 
3 Centralbl. f. inn. Med., 1900, vol. xxi., p. 41. 



HEMOGLOBIN. 12 1 

the gain ranging from 50 to 95 per cent, within a week's time. 
The injection of arsenic, on the contraiy, produced no effect upon 
the hemoglobin percentage, although it caused a marked and rapid 
increase in the number of red corpuscles. Similar effects from 
the administration of these drugs in the treatment of the different 
anemias may be observed as everyday clinical occurrences. 

Diminution in the amount of hemoglobin, as 
Variations indicated by the hemometer, is known as oligo- 
in Amount, chromemia, or achroiocythemia. It is a condition 
usually, but not invariably, associated with a cor- 
responding decrease in the number of erythrocytes. An ap- 
parent increase in the hemoglobin percentage may result from the 
concentration of the blood caused by a reduction in the quantity 
of blood plasma consequent to excessive drains upon the liquids 
of the body. By a similar physical mechanism, factors pro- 
ducing a dilution of the blood are capable of causing an ap- 
parent diminution in the hemoglobin. Marked oligochromemia 
is commonly observed in chlorosis, pernicious anemia, and 
leukemia ; and in the secondary anemias dependent upon such 
factors as hemorrhage, mineral poisoning, acute and chronic in- 
fections, malignant neoplasms, and constitutional diseases. The 
behavior of the hemoglobin under such conditions is more fully 
alluded to in connection with the lesions in question. Poggi, 1 from 
a series of experiments upon normal women, has shown that the 
hemoglobin is slightly lowered (10 or 15 per cent.) for a few days 
before menstruation, but with the establishment of the flow the 
oligochromemia soon disappears. The primary loss he attributes 
to retarded hemogenesis consequent to the lessened consumption 
of albumin occurring in menstruating women, while the subse- 
quent gain he explains by the increased functional activity of the 
hematopoietic organs. 

In passing, it may be of interest to compare the degree of 
hemoglobin loss in the various forms of anemia, as illustrated by 
the following averages determined by the writer : 



Average of 50 estimates in pernicious anemia 25.5 per cent. 

" " " " chlorosis 43.2 " " 

" " " " " leukemia 39.4 " " 

11 " " " " secondary anemia 55.2 " " 



Bierfreund's investigations 2 in Mickulicz's clinic have led to the 
current impression among surgeons that it is highly dangerous to 
give a general anesthetic to a patient whose hemoglobin percent- 
age is below 30 ; some operators regard 40 per cent, as the 

1 Policlin., Roma, 1899, vol. vi., p. I. 

2 Langenbeck's Archiv., 1890-91, vol. xli., p. 1. 



122 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 



lowest limit of safety, and refuse to employ any but a local anes- 
thetic in cases with an oligochromemia exceeding this figure, ex- 
cept under circumstances of imperative necessity. Any one, 
however, who has attempted to verify the correctness of this gen- 
eral belief must accept it with a shrug of the shoulders. The 
writer knows of four patients whose hemoglobin percentages all 
were below 30, in whom operations under general anesthesia with 
ether were followed by uneventful recovery ; in one instance (a 
pan-hysterectomy, lasting more than an hour and a half), the 
hemoglobin was but 21 per cent., yet no ill effects were observed. 

Assuming that in the normal adult 14 grammes 
Absolute represent the average amount of hemoglobin in 
Amount. 100 grammes of blood, the absolute amount of 
hemoglobin may be readily calculated, thus : 

tt 7 7* . . T _ Grammes of hemoglobin 

Hemoglobin percentage x 14 -r IOO = . J , , 

* r a in 100 grammes of blood. 

For example, in blood in which the percentage of hemoglobin, 
as determined by the hemometer, is found to be 40, the calcula- 
tion (40 x .14) gives the absolute amount of hemoglobin as 5.6 
grammes. 

The proportionate amount of hemoglobin con- 
Color tained in each red blood corpuscle, or its cor- 
Index. puscular richness in hemoglobin, is known as the 
color index, or blood quotient, or valeur globulaire. 
In normal blood the color index is theoretically expressed by the 
figure 1, although, practically, it varies from .95 to 1.05 in men, 
and from .9 to 1 in women. 1 

In those anemias in which the decrease in the amount 01 
hemoglobin in the blood is coincident with a proportionate de- 
crease in the number of erythrocytes, the color index remains 
practically at the normal figure. If, however, the cellular de- 
crease happens to be relatively greater than the hemoglobin 
loss, then the index will naturally be found to rise above normal ; 
thus, in pernicious anemia, in which condition the loss of cells 
is proportionately much greater than the loss of hemoglobin, 
high color indices, approaching or even exceeding 1.25, are fre- 
quently observed. On the contrary, if the hemoglobin loss is rela- 
tively more excessive than the corpuscular decrease, the color 
index falls below normal ; for example, in chlorosis, in which, as 
a rule, the decrease affects the hemoglobin much more strikingly 
than the erythrocytes, low indices, such as .50 or less are common. 

To calculate the color index, the percentage of hemoglobin is 

1 Oliver : Loc. cit. 



HEMOGLOBIN. 



123 



divided by the percentage of erythrocytes, the result being ex- 
pressed in decimals. In order to simplify this procedure, 5,000,- 
000 erythrocytes per cubic millimeter must be arbitrarily con- 
sidered as normal, or 100 per cent. To obtain the percentage of 
corpuscles, the actual number counted in one cubic millimeter of 
blood is simply multiplied by two, and two or three decimals 
pointed off from the left, depending upon whether the count is 
below or above the normal 5,000,000. The following examples 
serve to illustrate the calculation in several conditions : 
Normal Adult. 

Erythrocytes : 5,000,000 per cb. mm. (100 per cent.). 

Hemoglobin : 100 per cent. 

100 -5- 100 = 1 '. Color index. 
Secondary Anemia. 

Erythrocytes : 2,650,000 per cb. mm. (53 per cent.). 

Hemoglobin : 40 per cent. 

4° -s- 53 = -75 : Color index. 
Pernicious Anemia. 

Erythrocytes : 840,000 per cb. mm. (16.8 per cent.). 

Hemoglobin : 1 8 per cent. 

18 -f- 16.8 = 1.07 : Color index. 
Chlorosis. 

Erythrocytes : 4,100,000 per cb. mm. (82 per cent.). 
Hemoglobin : 32 per cent. 
32 ■—- 82 = .39 : Color index. 

These examples, of course, refer only to the usual blood-find- 
ings, for the color index is by no means always high in pernicious 
anemia, nor always low in chlorosis. The color index shows 
simply the relative relations of the hemoglobin and the corpus- 
cular percentages. It is only suggestive, not diagnostic of a 
specific blood disease. 

The term hemoglobinemia is used to designate 

Hemoglo- a condition in which the hemoglobin is dissolved 

binemia. from the corpuscular stroma, as the result of 
some pathological factor, and is held in solution 
by the blood plasma. In extreme instances this condition is 
sooner or later succeeded by hemoglobinuria. 

Among the most potent causal factors of hemoglobinemia are 
certain drugs which act as blood-poisons, when administered in 
toxic doses, of which the following are examples : arseniuretted 
hydrogen, sulphuretted hydrogen, potassium chlorate, carbolic acid, 
hydrochloric acid, sulphuric acid, pyrogallic acid, nitrobe?izol, anti- 
mony sulphide, iodine, naphthol, and many of the coal-tar deriva- 
tives, such as acetanilid, antipyrin, and phenacetin. A similar 



124 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 



liberation of the hemoglobin may be observed as the result of 
poisoning by certain varieties of mushrooms, by some snake- 
venoms, by the bite of scorpions, and by a number of vegetable 
glucosides. Sunstroke, extensive burns, and exposure to excessive 
cold, are also capable of giving rise to hemoglobinemia. Experi- 
mentally, hemoglobinemia may be produced by the transfusion 
of blood from one animal into the circulation of another belonging 
to a different species. 

Hemoglobinemia is observed with more or less constancy in a 
number of acute infectious diseases such as grave cases of septice- 
mia, diphtheria, malignant jaundice, syphilis, malarial fever, enteric 
fever, scarlet fever, yellow fever, typhus fever, and variola. It also 
may occur in scurvy, and in Raynaud 's disease, and is a prominent 
blood-finding in those two obscure conditions known as epidemic 
hemoglobinuria of the new-born, and paroxysmal hemoglobinuria. 

Hemoglobinemia may be readily detected by the following 
method, recommended by von Jaksch: 1 — A small amount of 
blood, drawn from the patient by means of a cupping-glass, is 
immediately placed in a refrigerator, in which it is allowed to re- 
main for twenty-four hours. In normal blood, the serum which 
separates at the expiration of this period, is of a perfectly clear 
straw-color, whereas if hemoglobinemia exists the serum is colored 
a beautiful ruby-red. If this hemoglobinemic serum is examined 
with the spectroscope, the two characteristic absorption bands of 
oxyhemoglobin may be observed. If it is coagulated by heat, a 
deep brown color is imparted to the coagulum. 

Methemoglobinemia, or the presence in the 
Methemoglo- circulating erythrocytes of methemoglobin, is 
binemia. produced by the action of a number of toxic 
substances, which, if given in sufficiently massive 
doses, may seriously or fatally cripple the oxygenating functions 
of the blood. Among the agencies which cause this conversion 
of oxyhemoglobin into methemoglobin are potassium chlorate, 
aniline, iodine, bromine, ether, turpentine , acetanilid, potassium per- 
manganate, hydrochinon, kairin, thallin, and pyrocatechin. The 
inhalation of amyl nitrite, and the intravenous injection of sodium 
nitrite also act in a similar manner. 

Spectroscopical examination of the blood is essential for the de- 
tection of methemoglobinemia. The spectrum of methemoglo- 
bin in alkaline solution shows three absorption bands : one 
well-marked band between C and D of Fraunhofer's lines and 
two others of much less distinct appearance, lying between D 
and E, each immediately adjacent to the lines. In acid and neu- 

Clinical Diagnosis," etc., London, 1897, 3d ed. 



HEMOGLOBIN. 



125 



tral solutions the spectrum of methemoglobin shows four absorp- 
tion bands : a decided one between C and D, two between D and 
E, and one closely adjacent to F. This spectrum, it is true, is 
identical with that produced by an acid solution of hematin, but 
it may be easily distinguished from the latter by the fact that 
the spectrum of methemoglobin, when acted upon by ammonium 



Fig. 35. 



Oxyhemogl obin 



Met hem oglobin 



Reduced Hemoglo- 
bin 



C 0 Hemoglobin 



c 



D 



5 6 











n 
































if 


















































jj 











Principal blood spectra. 



sulphide, changes first to that of oxyhemoglobin, and later to 
that of reduced hemoglobin, while when hematin is thus treated, 
a spectrum which shows two bands between D and E is produced. 

Aside from the bright, cherry-red color of the 
Carbon Mon- blood in coal-gas poisoning, the presence of car- 
oxide Hemo- bon monoxide hemoglobin may be determined by 
globin. spectroscopical examination, and by a number of 
distinctive chemical reactions. 
Recalling the characteristic spectrum of oxyhemoglobin ( two 
distinct absorption bands between D and E, the one nearest D 
being darker, narrower, and more sharply defined), it is found that 
in the spectrum of carbon monoxide hemoglobin these bands 
are replaced by two others, also between D and E, but nearer 
together, and somewhat closer to the violet end of the spectrum. 
This distinction, which may be so slight as to appear confusing, 
is at once emphasized by the fact that the addition of ammo- 



126 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 

nium sulphide has absolutely no effect upon the carbon monox- 
ide spectrum, while it transforms the spectrum of oxyhemoglo- 
bin into that of reduced hemoglobin. 

Carbon monoxide hemoglobin in the blood is also demonstra- 
ble by the following simple test devised by Hoppe-Seyler : 1 — A 
small quantity of blood, removed from the patient by means of 
a wet-cup, is mixed with twice its volume of a ten per cent, solu- 
tion of potassium hydrate. Thus treated, blood containing car- 
bon monoxide hemoglobin changes the color of the mixture to a 
rich cinnabar-red, while with normal blood the solution turns 
brownish-green. 

II. THE ERYTHROCYTES. 

The erythrocytes or red corpuscles are thin, 
Appearance flattened, biconcave discs, of sharply-defined, 
in regular outline, and of smooth, even surface. In 

Fresh Blood, the blood of the normal individual they do not 
possess a nucleus. When the corpuscle is ex- 
amined microscopically as it rests upon its flat surface, its cen- 
tral concavity is plainly indicated by a dark, central area sur- 
rounded by a narrower, lighter rim, as the periphery of the cell 
is brought into sharp focus ; changing to a pale, white center 
encircled by a darker periphery, as the objective is brought closer 
to the corpuscle. When viewed in profile the corpuscle is shaped 
somewhat like a slim dumb-bell, with regularly rounded poles 
tapering from either end toward a shallow central concavity on 
either surface. Their color, when examined singly under the 
microscope, is a pale greenish-yellow, but when collected to- 
gether in masses a more or less marked reddish tint becomes ap- 
parent. The erythrocytes possess a peculiar tendency of collect- 
ing and adhering together in more or less regularly arranged 
piles, like rolls of coins stacked up face to face, this being known 
as rouleaux formation. 

After withdrawal of the blood from the body various structural 
changes in the erythrocytes, commonly known as crenation, may 
be observed. In normal blood, the rapidity with which these 
changes progress depends upon the quantity of air which leaks 
in between the slide and the cover-glass, and thus causes de- 
generation of the corpuscular stroma. The development of one 
or more small, bright, highly-refractive spots in the body of the 
corpuscle, or a slight indentation of the cell's periphery are the 
most conspicuous indications of beginning crenation. As the 
process goes on, more and more of these hyaline points develop, 

1 Loc. cit. 



THE ERYTHROCYTES. 



127 



until finally the whole surface of the corpuscle becomes thickly 
studded with glistening, bead-like spines. As the stroma be- 
comes drier and drier, its typical biconcavity and sharply-cut out- 
line are lost, contracting strands of the stroma are seen to extend 
from point to point among the beaded projections, the periphery 
of the cell changes to a cogged rim, and finally the cell becomes 
shrunken and shrivelled up into a small, many-starred asterisk. 
Some of the erythrocytes become fragmented, and small bits of 
their stroma are observed to break off and float through the 
plasma. Others become progressively paler and paler, as the 
hemoglobin is dissolved out, until complete decoloration occurs. 
Still others become distorted into designs of every conceivable 
shape, so that their resemblance to the normal cell becomes most 
remote. These changes, which never occur in normal blood 
until the cells have been exposed to prolonged atmospheric in- 
fluence, must not be confused with similar alterations in the 
structure of the erythrocytes occurring as the result of patholog- 
ical states of the blood. The latter changes are described more 
fully in another place. (See page 141.) 

The finer structure of the erythrocyte is still a 
Histological mooted point among different histologists, the 
Structure, view most generally accepted regarding it as a 
homogeneous cell composed of • an insoluble 
spongy network, the stroma of Rollet, in the interstices or trabec- 
ular of which is embedded a soluble, finely granular substance, 
the hemoglobin, existing probably as a compound with some un- 
known constituent of the cell. In lieu of a distinct limiting 
membrane, the portions of the stroma nearest to the surface of 
the corpuscle are condensed, to protect it from injury during its 
movements through the blood stream. The corpuscles are highly 
elastic and contractile, to permit of the rapid and marked tempo- 
rary distortions of shape which they constantly undergo in the 
circulating blood. 

Other authorities, notably Schaffer, 1 disagree with this view, 
inclining rather toward the opinion advocated by the earlier in- 
vestigators, who considered the erythrocytes as vesicular masses, 
consisting of an external envelope enclosing a fluid contents. 
Thus, Schaffer believes that the cell consists of two distinct por- 
tions, a colored and a colorless, the former being a solution of 
hemoglobin, while the latter, or so-called stroma, consists chiefly 
of lecithin and cholesterin, together with a small amount of cell 
globulin. Without attempting to discuss the correctness of either 
of these two views, a single tangible reason for regarding the cor- 

^uain's "Anatomy," Phila., 1891, pt. 2, p. 210. 



128 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 

puscle according to Rollet's opinion may be stated, viz : the fact 
that exposure of blood to destructive temperatures results in 
fragmentation of the corpuscles into numerous minute portions, 
each one of which consists of a bit of hemoglobin-containing 
stroma. This obviously seems to disprove the existence of a 
limiting membrane, without further investigation. 

In the human body an active manufacture 
Origin and of red corpuscles constantly goes on during 
Life History, health, in order to compensate for the continuous 
drain on their number by the destruction of those 
cells which have become incapable of function and useless, their 
life cycle being run. That this reproduction is the direct answer 
to a call for new cells is proved by the prompt and rapid increase 
of corpuscles following the loss of blood from hemorrhage ; that 
such a manufacture is attempted in severe pathological conditions, 
although the attempts are sometimes abortive, is evinced by the 
large numbers of immature and misshapen erythrocytes which 
appear in the blood in certain of the grave anemias. 

In the adult it is generally conceded that the erythrocytes 
are reproduced in the red bone marrow, being developed from 
their direct antecedents, the nucleated erythrocytes or erythro- 
blasts, which exist in this tissue in large numbers. The erythro- 
blasts appear to multiply in the thin-walled capillaries and veins 
of the red marrow, and having lost their nuclei, become trans- 
formed into normally developed erythrocytes, which pass from 
the marrow blood channels into the general circulation. Some 
authorities have attributed to the spleen and lymphatic glands a 
share in the formation of the red cells, while others have main- 
tained that they may be transformed from the leucocytes in the 
circulating blood, but none of these theories has been associated 
with convincing evidence, so that it is fair to consider the red 
bone marrow the chief, if not the only, seat of production, in 
the light of our present knowledge of the subject. Hayem's 
ingenious theory, that the red corpuscles arise from the hema- 
toblasts, does not enjoy the confidence of modern investiga- 
tors. 

When finally the erythrocyte, after having executed its function 
for a certain length of time, becomes useless in its primary office 
as an oxygen carrier, its death ensues, the destruction of the 
cell probably taking place largely in the spleen, whence the 
freed hemoglobin is carried to the liver to be eliminated as bile 
pigment. Warthin's 1 recent studies apparently show that de- 
struction of the erythrocytes also occurs in the splenolymph 

^our. Boston Soc. of Med. Sci., 1901, vol. v., p. 414. 



THE ERYTHROCYTES. 



129 



glands, minute vascular sinuses situated chiefly in the retroperi- 
toneal and mediastinal tissues, and in the thyroid and thymus 
regions. The possibility that certain of the partly degenerate 
red corpuscles also undergo a certain form of repair, first in the 
spleen and then in the liver, rendering them still capable of func- 
tion, is an interesting but obviously unproved conjecture. 

The average diameter of the erythrocyte is about 
Size. 7.5^/ its average thickness being about 1.8 fi. Ac- 
cording to Gram, 2 the diameter appears to vary some- 
what with the geographical and climatic conditions surrounding 
the individual, being considerably larger in inhabitants of northern 
countries than in southerners, as the following average measure- 
ments of this observer attest : 



Hayem 3 distinguishes three different sizes : large, averaging 
8.5 /i in diameter; medium, averaging 7.5 fi in diameter; and 
small, averaging 6.5 f± in diameter. Of these three classes, ap- 
proximately 75 per cent, are of the medium size, while 12.5 per 
cent, each, are large and small. The diameter varies within some- 
what wider limits in the infant and in the young child than in the 
adult. It is, however, not materially influenced by sex. The 
pathological increase and decrease in the diameter of the erythro- 
cytes occurring in certain anemias, are discussed in another place. 

The normal number of erythrocytes in the 
Normal healthy male adult may be approximated at 
Number. 5,000,000 to the cubic millimeter of blood. 

Higher counts than this are frequently observed, 
however, especially in healthy, well developed men, so that this 
figure should be taken to represent a rather low average, subject 
to an upward fluctuation of half-a-million cells, and occasionally 
even more. In females a count of about 4,500,000 red cells per 
cubic millimeter may be regarded as normal. 

Arterial and venous blood contain practically the same number 
of corpuscles, the apparent slight increase in favor of the latter, 
mentioned by some observers, being within the limits of technical 
error. For a like reason, under normal conditions, peripheral 

1 The Greek letter 11 is used to represent a micromillimeter, or 1/1,000 of a milli- 
meter, which is a standard unit of measurement used in microscopy. 

2 Forschr. d. Med., 1884, vol. ii., p. 33. 

3 Loc. cit. 

9 



Country. 



Average Diameter. 



Italy .... 
France . . 
Germany, 
Norway . 



7 t0 7.5 fi 
7.5 to 7.6// 
7.8 fi 

8. 5, a 



130 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 

blood may be taken as representative of the blood of the entire 
body. Blood derived from dependent parts of the body contains 
a diminished proportion of corpuscular elements. Oliver's 1 
studies of this question have shown that blood from the finger 
invariably gives a higher count of red cells than blood from the 
toe, this disparity being explained by the fact that the larger 
quantity of lymph gravitating to the more dependent parts of the 
body causes a dilution of the blood in these areas. 

This term has been applied by Capps 2 to the 
Volume figure representing the percentage volume of the 
Index. individual erythrocyte, in contradistinction to the 
color index, which expresses the amount of hemo- 
globin in the single cell. It is calculated by dividing the percent- 
age volume of the erythrocytes as a whole, obtained by centrifu- 
galization of the blood, by the percentage number of erythrocytes, 
as determined by the actual count with the hemocytometer, the 
normal volume index being taken as 1.00. For example, the 
erythrocyte column, after centrifugalization with the hematocrit, 
reaches to the mark 40 on the capillary tube, indicating a total 
volume of 80 per cent.; while the count with the hemocytometer 
gives 3,000,000 cells per cubic millimeter, or 60 per cent, of the 
normal number. Then, 80 -~- 60, or 1.33, equals the volume in- 
dex, a figure which in this instance shows an increase of 33 per 
cent, in the volume of each corpuscle. As a general rule, it may 
be stated that the volume index and the color index rise and 
fall together, although the parallelism between the two is not al- 
ways closely maintained. The volume index is generally lowered 
in chlorosis, in leukemia, and in most of the secondary anemias, 
while in pernicious anemia it tends to rise above the normal 
standard. 

III. INFLUENCE OF PHYSIOLOGICAL FACTORS ON 
THE ERYTHROCYTES. 

Polycythemia, associated with a proportionately 
Age and Sex. high percentage of hemoglobin, is found in the 
blood of the new-born infant immediately after 
birth, the maximum counts being observed some time during the 
first twenty-four hours of life, after which period they progres- 
sively diminish until at the end of about eight or ten days an 
average of one million cells has been lost. Each period of nursing 
is generally followed by a prompt temporary decrease in the 
count, and a similar change has been observed as the effect of 

1 Loc. cit. 

2 Loc. cit. 



INFLUENCE OF PHYSIOLOGICAL FACTORS. 1 3 I 

premature ligation of the cord, at birth. Hayem 1 found an aver- 
age of 5,368,000 red corpuscles per cubic millimeter in 17 infants 
at birth, the highest count being 6,262,000, and the lowest 
4,340,000. The cause of this polycythemia is attributed to con- 
centration of the blood from the abstraction of water by the tissues 
to replace the fluids of the body lost during the first few days of 
life. As soon as this loss is made up by the ingestion of a 
sufficient amount of liquids by the child, the normal relation be- 
tween the liquid and the solid portions of the blood is reestab- 
lished, so that the polycythemia disappears. 

During the growth of the adult the average number of eryth- 
rocytes continues to rise, until the maximum number is attained 
at some time between the third and fifth decades, after which 
a decrease is observed, usually becoming more marked as the 
decline of life progresses. Schwinge 2 and others have shown 
that during the period of sexual activity the counts in females are 
generally lower than in males, but that after the climacteric the 
number of cells in the two sexes is practically identical. 

The influence of age and sex upon the number of red corpuscles 
is well illustrated in the following table prepared by Sorensen : 3 

Age. Males. Age. Females. 

5 to 8 days 5,769,500 1 to 14 days 5,560,800 

5 years 4,950,000 2 to 20 years 5,120,000 

19.5 to 22 years 5,600,000 15 to 28 years 4,820,000 

25 to 30 years 5,340,000 41 to 61 years 5,010,000 

50 to 52 years 5.137,000 

82 years 4,174,700 

There are no conspicuous changes in the num- 
Pregnancy, ber of erythrocytes in any of these conditions. 
Menstruation, In primiparae there is often a slight decrease in 
and the number of corpuscles, particularly in the 
Lactation, later months of pregnancy, but in multiparas 
this change is rarely observed. During men- 
struation there may be a trifling reduction caused by the physi- 
ological hemorrhage of the phenomenon, but the loss is rapidly 
made up in a few days' time. Sfameni 4 found that a transient 
polycythemia usually occurs shortly before the establishment of 
the menstrual flow, and that the average loss of hemoglobin and 
corpuscles, which takes place in the majority of cases during the 

1 Loc. cit. 

2 Pmiger's Archiv., 1898, vol. lxxiii., p. 299. 

3 Cited by von Limbeck : " Grundriss einer klinischn Pathologie des Blutes," 
Jena, 1896. 

4 Rassegna di ostetricia e ginecologia, Jan.-Feb., 1899. Abstr. in Centralbl. f. 
Gynakol., 1899, vol. xxiii., p. 13.II. 



132 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 

flow, does not exceed 4.5 per cent., the decrease being in direct 
proportion to the actual volume of blood lost. 

In healthy, robust women lactation is accompanied by a normal 
count, but in weak, young pregnant girls, particularly those of 
the "chlorotic age," a moderate reduction is sometimes observed. 
After delivery there is an oligocythemia, the intensity of which 
depends largely upon the amount of blood lost and upon the 
general health of the woman ; this loss of cells is gradually made 
up, and unless convalescence is delayed, reaches the normal by 
the second or third week after delivery. 

Well-developed, robust individuals average a 
Constitution larger percentage of red cells than the poorly- 
and nourished and weakly. In the former, counts 
Nutrition, much in excess of five million, and in the latter, 

counts of less than five million, are the rule. 
Fasting, inasmuch as it causes a drain upon the liquid elements 
of the intravascular system, may rapidly bring about an apparent 
polycythemia due to concentration of the blood, this increase in 
cells being in direct relation to the length of abstinence from food. 
Hayem 1 states that a twenty-four hours' fast will cause a gain of 
between four and five hundred thousand cells ; while the experi- 
ments of Reyne 2 on a dog, starved to death after a twenty-four 
days' fast, showed an increase of 2,500,000 corpuscles at the ex- 
piration of this period. 

Physical labor prolonged to the point of fatigue 
Fatigue. appreciably diminishes the number of erythro- 
cytes. Cadet's 3 investigations of the blood of a 
number of peasants, examined after two months of hard field 
labor during the summer, showed a moderate oligocythemia — in 
one instance a loss of over one million cells, and in the others 
diminutions averaging about one-half of this figure. Cadet be- 
lieves that this anemia is referable to a true blood destruction, 
and notes as a rather mythical support of this view that the blood 
plaques were increased in these cases. 

Within an hour or two after a meal there is 
Digestion, a slight, transitory increase in the number of 
Food. erythrocytes, soon followed by a decrease corre- 
sponding to the period of digestion and aver- 
aging a loss of from one quarter to three quarters of a million 
cells. The preliminary rise has been attributed to abstrac- 
tion of liquids from the blood-vessels consequent to the pro- 

1 Loc. cit. 

2 Cited by Hayem, loc. cit. 

3 Ibid. 



INFLUENCE OF PHYSIOLOGICAL FACTORS. 



133 



fuse outpouring of the gastric secretions ; the subsequent fall 
depends upon temporary dilution of the blood during digestion, 
and stands in inverse ratio to the leucocyte count. Oliver 1 
states that these variations are not affected by the taking of 
liquids with meals, for he has noticed that they were quite as pro- 
nounced when water was withheld. The following table, from 
Von Limbeck, 1 illustrates the variations in the red and white cells 
caused by taking food. 

Time. Erythrocytes. Leucocytes. Hemoglobin. 

II:I5A.M. 5, 553,000 7,666 98%. 

12 M. Dinner of meat and farinaceous food. 

12:15 P. M- 5>320,ooo 6,166 — 

1:15 P. M. 5,480,000 8,500 — 

2:15 P. M. 4,733,000 12,000 — 

3:15 P. M. 4,872,000 14,000 89%. 

4:15 P. M. 4,720,000 10,830 — 

Hayem 1 believes that meat eaters average a higher percentage of 
red corpuscles than vegetarians, on account of the more nitrogenous 
character of their food, and that a diet of fats and albuminoids is 
most favorable for the increase of the cellular elements of the blood. 

The habitual polycythemia of individuals living 
High in high altitudes is an interesting and inadequately 

Altitudes, explained fact in hematology. Viault, 2 Wolff 
and Koeppe, 3 Egger 4 and other observers have 
shown the invariable occurrence of this polycythemia both in 
inhabitants of elevated districts and in the occasional visitor. In 
the case of the latter, as the individual ascends from the sea- 
level to the mountainous district, a rapid increase in corpuscles 
and in hemoglobin develops, this increase bearing a certain rela- 
tion to the height ascended, and becoming apparent usually 
within twenty-four or forty-eight hours after his arrival in the 
highland. Viault counted 8,000,000 erythrocytes to the cubic 
millimeter in the residents on the Cordilleras, at an elevation of 
14,274 feet above the sea-level; Egger counted 7,000,000 at 
Arosa, at a height of 6,100 feet; and Wolff and Koeppe found an 
average of 5,970,000 in dwellers at Reiboldsgriin, at a height of 
2,257 f eet - Oliver 5 relates the interesting experience of finding in 
his own blood, during a stay at Davos Platz, at an elevation of 
5,200 feet, an increase of corpuscles within twenty-four hours after 
his arrival, the maximum count, 5,550,000, being attained within 
seven days, and the number declining within five days after his 

1 Loc. cit. 

2 Comptes Rendus, 1890, vol. iii., p. 917. 
3 Miinch. med. Woch., 1893, vol. xl., p. 904. 
4 XII. Congress f. Innere Med., Weisbaden, 1 893. 
5 Loc. cit. 



134 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 

return to London. The hemoglobin changes, which accompany 
these corpuscular alterations, are never so marked as the latter, 
both the rise and the fall being less rapid ; consequently it is com- 
mon to find a low color index at first, whereas, later, inasmuch 
as the rapidity of the cellular decrease is greater than the fall in 
hemoglobin, a high color index is apt to persist for some time after 
return to the lowland. 

The following table taken from Koeppe, 1 illustrates the fact that 
the higher the altitude, the higher is the count of erythrocytes : 



Height Above Count of 

Place. Sea-level. Erythrocytes. Author. 

Christiania o 4,974,000 Laache. 

Gottingen 148 meters. 5,225,000 Schafer. 

Tubingen 314 " 5,322,000 Reinert. 

Zurich 414 " 5,752,000 Stierlin. 

Auerbach 425 " 5,748,000 Koeppe. 

Reiboldsgriin 700 " 5,900,000 Koeppe. 

Arosa 1,800 " 7,000,000 Eggar. 



The Cordilleras ...4,392 " 8,000,000 Viault. 

Concentration of the blood doubtless explains the polycythe- 
mia of high altitudes, this change being due largely to the great 
loss of body fluids (Grawitz), and partly to the increased arterial 
tension (Oliver) arising from a rarefied atmosphere. Koeppe's 
ingenious theory that the process mirrors an actual manufacture 
of new cells is scarcely tenable, for although this observer has 
found numerous microcytes and poikilocytes coincidentally with 
the appearance of the polycythemia, normoblasts were not de- 
tected, as an evidence of rapid hemogenesis, nor did such signs 
of excessive blood destruction as icterus and hemoglobinuria de- 
velop, as the increased count rapidly declined, on the individual's 
descent to a lower level. 

It has recently been urged that in high elevations the effect 
upon the hemocytometer of atmospheric pressure and tempera- 
ture may be the real secret of the cellular increase, but how such 
influences act, if, indeed, they are active, is unknown. 

IV. PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. 

True ameboid movements of the erythrocytes 
Ameboid are sometimes observed, as the result of the effect 
Motility. of globulicidal agents, or of some pathological 
state of the blood, such as a severe, high-grade 
anemia. The inherent elastic and contractile qualities shown by 
the cells, by virtue of which they undergo various changes in 

1 Loc. cit. 



PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. I 3 5 



shape while floating about in the plasma, must not be confounded 
with the actual ameboid motility which they exhibit in disease. 
The molecular dancing movements of bits of fragmented corpus- 
cles, and the characteristic motility of the intracellular hyaline 
malarial parasite, also must be distinguished from the progressive, 
deliberate characteristics of the truly ameboid red blood cell. 

Within the body the hemoglobin and other 

Alterations constituents of the erythrocytes are preserved 
in intact within the corpuscular stroma by the com- 

Isotonicity. position of the blood plasma, which is such that 
a perfect osmotic balance is constantly main- 
tained. Outside of the body, if this relationship is disturbed by the 
addition of distilled water to a specimen of blood, thus lowering 
the concentration of the plasma, a rapid discharge of hemoglobin 
from the corpuscle into the surrounding liquid ensues, but the 
addition of saline solutions of a definite strength prevent such a 
change. Solutions of salts of just sufficient concentration to pre- 
serve the corpuscles and to prevent removal of their elements 
are known as isotonic ; solutions of greater strength are termed 
hypertonic, and those of lesser strength hypotonic. In normal 
blood it has been determined that the isotonicity of the eryth- 
rocyte usually ranges from about 0.48 to 0.46 per cent. NaCl ; 
that is, salt solutions of this concentration are just sufficient to 
prevent the discharge of hemoglobin by the cell, although it may 
swell by taking up water. A 0.9 per cent, or " normal " salt 
solution not only preserves the hemoglobin within the cell, but 
also prevents alterations in its size and contour. 

Owing to the conflicting results which have been obtained by 
different investigators, the isotonicity of the erythrocytes in differ- 
ent diseases is of little clinical value. Stengel 1 found the per- 
centage 0.52 and 0.6 in two cases of pernicious anemia, yet in 
other cases the figures were normal ; in other diseases marked by 
anemia, such as carcinoma, hepatic cirrhosis, renal disease, and 
tuberculosis, he found that the variations were trivial. Von Lim- 
beck 2 found that the isotonicity was usually, but not invariably, 
increased in high-grade secondary anemias, in leukemia, and in 
many of the acute infections, while it was decreased in chlorosis, 
and in catarrhal icterus. A decidedly increased isotonicity was 
found by Vicarelli 3 in pregnant and nursing women. As a 
general rule, it is believed that degenerative changes in the eryth- 
rocytes, whatever their nature, predispose to dissociation of hem- 

1 Loc. cit. 
2 Loc. cit. 

3 Cited by von Limbeck, loc. cit. 



I36 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 

oglobin from the stroma, and that in such instances the isotonic 
percentages are higher than normal. 

In the fresh specimen of blood, exaggeration 

Hypervis- of the adhesive properties of the erythrocytes 
cosity. may be observed in a number of conditions, but 
up to the present time no special clinical signifi- 
cance has been assigned to the phenomenon. It occurs to some 
extent in most inflammatory diseases, and, according to Hayem, 1 
is often seen in the anemias associated with marked cachexia. 
Striking examples of hyperviscosity result when the erythrocytes 
are subjected to the action of various poisons, notably snake 
venom, and of heterogeneous pathological blood-serum. From 
the effect of such influences the erythrocytes, instead of forming 
normal rouleaux, tend to adhere together in large, irregular 
masses in which the distinctive characteristics of the cells are 
masked or lost. The individual cells, unattached to such a 
mass, may exhibit every possible variety of distortion, losing 
their typical biconcavity and regular disc-like appearance, and 
becoming converted into elongated, misshapen bodies. It fre- 
quently happens that the cell is provided with one or more 
long, delicate processes several times the length of its diameter, 
this being due to the adhesion of a bit of the stroma to the cover- 
glass while preparing the specimen ; in the spread film it will be 
noted that these processes all point in the same direction. 

Changes in the shape and size of the eryth- 
Deformities rocytes are common in all anemias which reach 
of a severe grade, the degree of such deformities 

Shape and corresponding closely to the intensity of the 
Size. anemic process. The diameter of the cells may 
be more or less uniformly increased or decreased, 
and such pronounced alterations in their shape may occur that 
many of them bear but slight resemblance to the typical discs of 
normal blood. (Plate I.) 

When the corpuscle becomes greatly enlarged in diameter it is 
known as a megalocyte or macrocyte, the presence of large num- 
bers of such cells being known as megalocytosis or macrocytosis. 
The diameter of a megalocyte generally varies from 9 to 12^, 
but sometimes much larger forms are seen, measuring as much as 
20 p.. They are present in the severer anemias, especially in the 
pernicious form, in which they constantly occur in large numbers. 
The megalocyte found in this disease is usually characterized by 
an excess of hemoglobin, while in the secondary anemias such 
cells are generally deficient in their hemoglobin content. 

1 Loc. cit. 



PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. 1 37 

The smaller forms, the microcytes, illustrate the extreme de- 
crease in size of the red cell under pathological conditions. The 
microcyte is an extremely small globular body, measuring from 
about 3 to 5 a in diameter. It is found in all the varieties of 
anemia, but is most commonly associated with chlorosis, and with 
the moderately developed secondary forms. When abundantly 
found in the blood, the condition is known as microcytosis. 

Eichhorsfs corpuscles are deeply colored, highly-refractive mi- 
crocytes, about 3 u. in diameter, and usually of regularly spherical 
shape. They were once regarded as pathognomonic of pernicious 
anemia, but are now considered diagnostic of no especial condi- 
tion, being frequently found in severe anemias of any type, and 
often being absent in pernicious anemia. 

It seems reasonable to infer that deformities in the size of the 
erythrocyte are referable chiefly to two different factors : to faulty 
hemogenesis, and to degenerative changes of the corpuscle which 
lead to alterations in its histological structure. Megalocytes, for 
example, may in some instances represent an actual giantism of 
the cell, bred in the marrow from correspondingly large-sized 
nucleated antecedents ; in other instances (of which those exceed- 
ingly pale, " washed out" forms are examples) their abnormal 
size may be attributed to hydropic enlargement, resulting from 
their imbibition of fluids from the surrounding plasma. Micro- 
cytes may enter the circulating blood as such, or, as is frequently 
the case, they may be the products of corpuscular budding and 
fragmentation. 

In severe forms of anemia, characterized by excessive cellular 
loss, there appears also to be a tendency toward a compensatory 
hypertrophy of many of the erythrocytes, in order thus to in- 
crease the oxygen-carrying capacity of the blood, which, were it 
not for these numerous megalocytes, might in some instances be 
too limited to sustain life. 

Poikilocytes are erythrocytes deformed in shape as the result 
of some pathological condition of the blood. Poikilocytosis, the 
name by which this condition is designated, is akin to crenation 
in so far as in both conditions the cells may be similarly distorted 
and misshapen. But it is unlike crenation for the reason that 
poikilocytosis is a pathological condition, and demonstrable the 
moment the blood is withdrawn from the body ; while crenation 
is a physiological phenomenon depending upon external influences 
for its production, and never occurring until the blood has re- 
mained exposed to the air for some time. Poikilocytes may be 
of large or small size, the varieties of deformities being infinite, 
and the degree marked or slight in relation to the nature of the 



I38 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 



blood disease. Some of the cells may resemble the shape of a 
gourd or a horseshoe, others may be drawn out at both ends until 
they form a spindle-shaped or oval body, while others appear 
sharply beaked at one or more points, or shaped like a dagger or 
the blade of a tomahawk. Occasionally very minute, rapidly- 
oscillating, rod-shaped forms are seen, morphologically not un- 
like large, unstained bacilli — the pseudo-bacilli of Hay em. These 
rod-shaped forms are products of corpuscular fragmentation, and 
indicate lowered vitality and feeble powers of resistance to the 
pathological influences affecting the cells. 

Poikilocytosis is not characteristic of any single disease of the 
blood, but it is generally most marked in the grave forms of 
primary anemia, such as leukemia and pernicious anemia. Oval- 
shaped red cells are considered by Cabot 1 as particularly abundant 
in the latter disease. 

The conditions of deformity, affecting the shape and size of the 
erythrocytes are nearly always associated. As a general rule, it 
may be stated that in the milder types of anemia small -sized, 
slightly-deformed poikilocytes and microcytes are most common ; 
and that in the severe forms, large-sized, conspicuously-distorted 
poikilocytes and megalocytes predominate. 

Loss of color by the erythrocytes, which pro- 
Endoglobular gresses hand in hand with alterations in their 
Degeneration, size and shape and other structural changes, is 
regarded as a degenerative process, of purely 
endoglobular nature. It is observed in the fresh specimen of 
blood in many severe anemic conditions, especially in the anemias 
associated with infectious diseases, such as variola, typhus fever, 
and grave septicemia and pyemia. 

The decoloration may commence in one or more spots, or it 
may equally involve the whole surface of the corpuscle, beginning 
at its center and spreading progressively toward its periphery. 
Clear, hyaline areas of oval, round, or elongated shape, appear 
within the stroma, in some instances sharply contrasting with the 
relatively dark color of the hemoglobin, but in other instances 
imperceptibly blending with the tint of the surrounding cell-body. 
The active motility of these decolorized spots must be carefully 
distinguished from the ameboid movements of the young malarial 
parasite. Complete decoloration transforms the cell into a mere 
colorless shell or " phantom," which would be practically invisible 
were it not for its faintly colored periphery. Such cells are known 
as Ponfick's shadozv corpuscles, or as Hayem's achromacytes. 

l " A Guide to the Clinical Examination of the Blood," 3d edition, N. Y., 1898, 
p. 140. 



PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. 1 39 



Maragliano 1 and Castellino have minutely described this proc- 
ess of decoloration, along with certain other alterations in the 
structure of the erythrocyte, which they have termed endoglobn- 
lar necrosis. This process first becomes apparent by a visible 
enlargement of the central concavity of the corpuscle, together 
with a simultaneous fading away of the hemoglobin in this situ- 
ation. This central area of pallor gradually spreads toward the 
periphery of the cell, until finally the latter alone shows evidence 
of containing coloring matter. Such a corpuscle when examined 
on cross-section appears to be shaped like the figure 8. Frag- 
mentation of this delicate rim of coloring matter may occur, in 
event of which a number of independent rod-like bits of stroma 



Fig. 36. 




Degenerative changes in the erythrocytes. 

are formed. The decolorized area is not always symmetrical, so 
that frequently various strikingly bizarre designs, widely differing 
in shape and appearance, may be observed. It has been determined 
that in the dried blood-film these areas of decoloration show a de- 
cided affinity for basic stains, such as methylene-blue and thionin. 

Total cellular necrosis, also described by the 
Total authors mentioned above, represents a phase 
Necrosis. of structural degeneration in the erythrocyte 
of more advanced development than the endo- 
globular changes. This process begins with the development of 
several small elevations or corrugations in the stroma of the cor- 
puscle, which gradually multiply, increase in size, and change in 
shape until the larger portion of the cell's surface is thus de- 
formed. Ameboid movements are seen to begin, as if the entire 
cell as a whole were involved, the final stage of the process re- 

1 XI. Congress f. inn. Med., Leipzig, 1892. 



140 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 

suiting in the formation of a poikilocyte, from which body points 
and small fragments are observed to break off, and to float free 
in the plasma. Decoloration, starting usually from a single point 
and in time affecting the whole stroma, also accompanies this 
necrotic alteration. On cross-section, the cell appears as an 
elongated, thin rod, with rounded poles. 

Endoglobular degeneration and total necrosis of the erythro- 
cytes may be observed in both normal and in pathological blood. 
In normal blood they occur as the result of prolonged contact 
with the air, the endoglobular phase becoming first apparent 
within from thirty to seventy minutes, and the total necrosis in 
from three to four hours, after the preparation of the specimen. 
In pathological blood the changes are thought to be due chiefly 
to increased globulicidal properties of the plasma whereby intra- 
vascular necrosis is excited, and partly to decreased resistance 
of the erythrocytes in consequence of which their degeneration 
is abnormally hastened by contact with normal plasma, and by 
exposure to extraneous influences. In disease, it follows that 
they are demonstrable immediately or very shortly after the blood 
has been withdrawn, and that the development of the changes 
occurs with much greater rapidity than in normal blood. The 
endoglobular changes are regarded as a more favorable prog- 
nostic sign than the total necrosis, being usually associated with 
anemias of less severe character than those in which the latter 
process prevails. 

The normal erythrocyte, when fixed and 
Atypical stained with the aniline dyes, according to one of 
Staining Re- the methods described in another section, pos- 
action. sesses a strong affinity for a single, acid stain ; 

it is therefore termed monochromatophilic . When 
solutions are used containing both acid and basic dyes, such 
as eosin and methylene-blue or eosin and hematoxylin, the nor- 
mal erythrocyte is always stained by the eosin ; and with Ehr- 
lich's triple mixture, which is so formulated that acid, basic, or 
so-called neutral principle may be selected by the elements sub- 
jected to its action, according to their affinities, the erythrocyte 
invariably is colored by the orange G of the mixture. (Plate I.) 

In certain morbid conditions some of the corpuscles lose their 
affinity for the acid stain, and with mixtures of both acid and 
basic dyes are stained atypically by either or both elements. 
Such corpuscles are said to be polychromatophilic . Thus, when 
stained with an eosin and methylene-blue mixture, they are 
tinged a dirty grayish-purple or violet, instead of the rose color 
of eosin ; and with the triple mixture they may be stained pur- 



PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. 



HI 



pie, or reddish-brown, or pale yellowish-pink flecked here and 
there with shadings of a darker red. (Plate I.) 

In polychromatophilic corpuscles the staining is apt to be 
very unevenly shaded, often being quite dark in spots, especially 
around the periphery* of the cell and the margin of the nucleus, 
if the cell be nucleated. These color changes affect not only 
the protoplasm, but the nucleus, as well, and are strongly em- 
phasized in megaloblasts, the nuclei of which may show every sort 
of color combination. The more deficient the corpuscle in hemo- 
globin, the more decided its polychromatophilic tendency ; and 
the more strikingly the latter is developed, the more intense the 
cell's affinity toward the basic element of the stain. 

Polychromatophilia may occur in severe forms of anemia due 
to any cause, and it is especially noted in two of the primary va- 
rieties — pernicious anemia, and spleno-medullary leukemia, in 
both of which conditions the process is a prominent character- 
istic of the blood-picture. 

Nucleated erythrocytes, or erythroblasts, are 
Nucleation. found in the blood of the adult only during the 
existence of pathological conditions, but occur 
in large numbers in the blood of the fetus, and occasionally in 
the infant during the first few days of life. Being invisible in the 
fresh blood, they must be studied in the dried, stained specimen. 
In such preparations the finer structure of their nucleus, which 
bears a special affinity for the basic aniline dyes, may be beauti- 
fully illustrated by the use of solutions containing methylene- 
blue, methyl-green, and hematoxylin. 

According to their size and nuclear characteristics the ery- 
throblasts are designated as normoblasts, megaloblasts, and mi- 
croblasts. Certain intermediate forms are also common, some- 
times termed mesoblasts, such cells being atypical, and sharing 
characteristics of both the normoblast and the megaloblast. 

Normoblasts. (Plate I.) The normoblast is a nucleated ery- 
throcyte of about the general size and shape of the normal erythro- 
cyte. In the commonest variety the nucleus is round or ovoid in 
shape, very deeply stained, and situated rather toward the periph- 
ery of the cell than in the exact center, its diameter approximat- 
ing more than one-half that of the corpuscle which it occupies. In 
some of the cells it appears to have become partly or completely 
extruded from the protoplasm, lying either somewhat over the 
periphery of the cell, or being completely detached from it, free in 
the plasma. The nucleus may be single, or partly divided by 
constricting bands of chromatin into a figure like a dumb-bell or 
a clover-leaf, or completely divided into several small, round 



142 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 

sections. More rarely, karyokinesis may be observed. In care- 
fully stained films it will be noted that the nuclear framework of 
the typical normoblast consists of a rather sharply defined net- 
work of chromatin having relatively wide intervening open spaces, 
so that the general appearance of the nucleus is not unlike that 
of a coarse net. 

The protoplasm of this cell is usually of regular outline along 
the periphery, stains somewhat more intensely than that of the 
normal erythrocyte, and may show distinct evidences of poly- 
chromatophilia, this characteristic being especially marked in forms 
with dividing nuclei. 

The normoblast is regarded as the immediate antecedent of the 
normal erythrocyte or normocyte, into which it becomes trans- 
formed by the loss of its nuclear structure. The exact manner 
in which the nucleus is disposed of has long been a bone of con- 
tention among histologists, and even at the present time views on 
this question should be held but tentatively, notwithstanding many 
exhaustive investigations, especially those of the German school. 
According to the views of Rindfleisch, 1 it is lost by extrusion 
from the cell body, which thus becomes a normal erythrocyte, 
while the free nucleus, to which a small fringe of protoplasm still 
remains adherent, collects from the plasma material by virtue of 
which it ultimately develops into a new erythroblast. Ehrlich 2 
believes that in blood rich in normoblasts a series of connected 
pictures may be observed, showing that the normoblast becomes 
transformed into the erythrocyte by the extrusion or emigration 
of the nucleus. The later investigations of Neumann and K61- 
liker, 3 however, tend to prove that the nucleus is disposed of by 
its destruction and absorption within the cell, and that its ap- 
parent extrusion from the stroma is simply the result of mechan- 
ical influences. Pappenheim and Israel 4 also believe that the 
normoblasts nucleus disappears by decay and solution within the 
boely of the corpuscle, and that the apparently extruded nuclei 
are to be taken as an evidence of the process of plasmolysis, or 
a solution of the protoplasm of the cells once containing nuclei. 
To attempt a reconciliation of these diametrically opposed views 
is a task for future workers to undertake. Meanwhile, the general 
trend of opinion inclines toward the theory of nuclear solution 
within the corpuscle, and regards the so-called free nuclei of the 
normoblasts simply as artefacts. 

1 Archiv. f. mikroskop. Anat., 1880, vol. xvii., p. I. 
2 Loc. cit. 

3 Zeitschr. f. klin. Med., 1881, vol. iii., p. 41 1. 

4 Virchow' s Archiv. , 1896, vol. cxlv., p. 587 ; also, Pappenheim : Inaug. Dissert.,. 
Berlin, 1895. 



PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. 



143 



Normoblasts exist in the red bone marrow of the normal indi- 
vidual, but are found in the circulating blood only when the 
marrow, in consequence of pressing demands made upon it for 
the rapid manufacture of new erythrocytes, becomes unable to 
furnish an adequate supply of perfectly developed cells, so that 
some of these immature, nucleated forms prematurely leave their 
birth-place in the marrow, and pass into the blood stream in com- 
pany with large numbers of mature, non-nucleated discs. Normo- 
blasts are associated with lesions in which active hemogenesis 
of the normal type is stimulated, being the prevailing type of 
erythroblast in the anemias resulting from hemorrhage, and in 
other severe anemias of a secondary type. They sometimes ap- 
pear in the blood in successive crops of large numbers during the 
course of certain severe anemias, this phenomenon having been 
termed by von Noorden 1 a blood crisis. Blood crises, which are 
of abrupt onset and of brief duration, lasting but a few hours, 
are usually the direct precursors of an increase in the erythro- 
cyte count and in the hemoglobin percentage, being therefore 
a favorable sign indicating regeneration of the blood. They occur 
with especial frequency after loss of blood from hemorrhage, and 
in chlorosis, and are not uncommon in long-standing cases of 
spleno-medullary leukemia and primary pernicious anemia in 
which diseases periods of temporary improvement are likely to 
take place from time to time. 

Megaloblasts. (Plate I.) The megaloblast is much larger in size 
than the normoblast, and contains a single, large, pale-staining 
nucleus which occupies the greater part of the cell body. Both 
cell and nucleus are round or ovoid in shape, the diameter of the 
former being from about 11 to 20 fi, and that of the latter from 6 
to 10 fi. The greatest extremes of these measurements apply to 
those forms which are seen with relative infrequency, for the meg- 
aloblast most commonly observed does not usually measure more 
than 12 fi. in diameter, with a nucleus of proportionate size. The 
nucleus, which may be situated either in or away from the center 
of the cell, is composed of a chromatin network having relatively 
small intervening open spaces, so that the nuclear structure is 
decidedly more delicate and less well-defined than that of the 
normoblast. With the triacid solution it stains pale green or 
blue, or it may show every sort of irregular tinctorial reaction 
to the aniline dyes, certain portions being deeply stained, while 
other parts are but faintly colored ; the undertone of green or 
blue is frequently stippled with fine dots of purple or of brilliant 
crimson, especially about the periphery; or it may be mottled and 

1 Charite-Annalen, 1891, vol. xvi., p. 217. 



144 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 

splotched here and there with areas of purple or of dark blue. 
The nucleus usually is sharply differentiated from the body of the 
cell by a distinct white margin which encircles it and is thrown out 
in bold relief by the deep staining of the nuclear and cell bodies 
on either side. The protoplasm of the megaloblast often seems 
swollen and enlarged, and appears to contain areas of depression 
and elevation at different points ; it is sometimes quite round or 
oval in contour, and sometimes more or less deformed. It is 
usually polychromatophilic, and, like the nucleus, may show 
the greatest variety of color combinations. Some cells stain a 
dull brownish-yellow color with deeper shadings of a burnt- 
sienna tint in the neighborhood of the nucleus and of the periph- 
ery; others have an undertone of crimson, as if the stain con- 
tained an excess of fuchsin, and are streaked and dotted with 
yellow and tan-colored patches ; still others stain a diffuse purple, 
blending in spots into a light pink. 

The megaloblast is an element of the bone marrow of the young 
fetus, and is totally foreign both to the marrow and the blood of 
the normal adult. According to the views of Ehrlich, it repre- 
sents the immediate antecedent of the megalocyte into which it 
develops by the absorption of its nucleus. Apparent extrusion 
of megaloblastic nuclei is never observed. Megaloblasts are 
found in the circulating blood only under conditions in which the 
blood-making organs have reverted more or less to the fetal 
type, so that their presence in the circulation is considered to 
indicate that a sluggish hemogenesis of embryonal character exists. 
The significance of megaloblasts, therefore, is diametrically op- 
posed to that of normoblasts, for, while the latter are regarded as 
an expression of blood regeneration, and are considered to be of 
favorable prognostic significance, the former must be looked on 
as an evidence of degeneration of the hematopoietic organs, and, 
consequently, are of grave prognosis. 

Megaloblasts are found in the blood, almost invariably in as- 
sociation with normoblasts, in various anemias of marked severity-, 
but in only three conditions, viz., primary pernicious anemia, 
certain cases of anemia due to bothriocephalus latns infection, 
and nitrobenzole poisoning, have these cells been found to con- 
stitute the prevailing type of erythroblast. 

In typical cases of pernicious anemia their prevalence is gener- 
ally admitted to be a sign that in this disease the bone marrow, 
in consequence of its reversion to a fetal type, throws into the 
blood stream large numbers of these blood cells of embryonal 
character, these degenerative changes, the presence of megalo- 
blasts, overshadowing the regenerative changes, or the presence 



PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. I45 



of normoblasts. In bothriocephalus anemia, in which also the 
megaloblasts may outnumber the normoblasts, it is believed that 
the toxines produced by the parasite cause changes in the 
hematopoietic organs precisely similar to those found in pernicious 
anemia. In a single case of nitrobenzole poisoning, reported by 
Ehrlich and Lindenthal, 1 large numbers of erythroblasts were 
noted ; normoblasts predominated at first, but in the later stages 
of the intoxication they were outnumbered by megaloblasts. In 
other grave anemias, notably in leukemia, the regenerative signs 
appear to be more active than the degenerative, for, while in these 
conditions megaloblasts are frequently found, they are never 
numerous, being outnumbered by the normoblasts. 

In the following table the principal points of distinction between 
the normoblast and the megaloblast are emphasized : 





Normoblast. 


Megaloblast. 


Size. 


7.5 to IO f£. 


II to 20 fl. 


Nucleus. 


Sharply defined. 
Intensely basic. 
Coarsely meshed. 
Occupies about one-half of 
cell-body. 


Dully defined. 

Feebly basic. 

Delicately meshed. 

Occupies greater part of cell-body. 


Protoplasm. 


Sometimes very scanty, 
and of ragged outline. 
Occasionally polychro-* 
matophilic. 


Frequently appears swollen ; out- 
line fairly regular, but surface 
undulating in many cells. 

Striking tendency toward poly- 
chromatophilia. 


Histological 
Significance. 


Typical of active, adult 
hemogenesis. 


Typical of sluggish, embryonal 
hemogenesis. 


Occurrence. 


Prevailing type of ery- 
throblast in anemias 
with active blood re- 
generation. 


Prevailing type of erythroblast in 
anemias with megaloblastic de- 
generation of the bone marrow. 



Microblasts. The microblast, which is the rarest form of nu- 
cleated erythrocyte, is a cell usually not larger than 5 or 6 fi in 
diameter, and often of smaller size. It consists of a deeply stained, 
round nucleus like that of the normoblast, encircled by a frag- 
ment of ragged protoplasm of a dull brownish-yellow tint, in films 
stained with the triacid solution. Microblasts are thought to be 
simply forms of the normoblast in a more or less advanced stage 
of protoplasm degeneration, this process accounting for the char- 
acteristic scantiness and frayed-out appearance of their cell-body. 
Their clinical significance, naturally, is identical with that of the 
normoblast. 

1 Zeitschr. f. klin. Med., 1896, vol. xxx., p. 427. 

10 



I46 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 

From what has been stated above, it may be concluded that 
normoblasts and megaloblasts constitute two distinct classes 
of nucleated erythrocytes, each evidencing a separate type 
of blood-formation, and each carrying a different clinical mean- 
ing. Normoblasts, being an adult type of cell, have sharply 
denned, dense, deeply stained nuclei ; megaloblasts, being an 
embryonal type of cell, have poorly denned, delicate, feebly 
stained nuclei. It is these peculiarities of the nuclear structure 
that are all-important in determining the class to which a nu- 
cleated cell belongs — of more importance, in fact, than the size 
of the cell. 

Atypical Erythroblasts. In some of the severer anemias, notably 
in spleno-medullary leukemia and in pernicious anemia, various 
atypical erythroblasts are frequently found, corresponding partly 
to one and partly to the other of the first two species of cells 
described above. The so-called " mesoblasts," which maybe re- 
garded either as abnormally large normoblasts or as abnormally 
small megaloblasts, are in some instances almost as numerous as 
the typical forms of erythroblasts. It is sometimes impossible 
accurately to determine to which type such cells belong, but 
usually they may be classified by taking as criteria for differentia- 
tion the nuclear characteristics referred to in the preceding 
paragraph. In the triple stained specimen of blood the two fol- 
lowing commoner forms of atypical erythroblasts may be rec- 
ognized : — 

1. Corpuscles about 8 or 10 p. in diameter, containing a rela- 
tively large, round or ovoid nucleus, encircled by a distinct hya- 
line ring, and composed of a finely-meshed chromatin framework. 
The nucleus stains a pale green color, and is often filled with 
finely stippled areas of brilliant crimson. The cell-body is usually 
of regular outline, and, as a rule, is decidedly polychromatophilic. 
Such cells may be regarded as dwarf forms of megaloblasts, with 
which they may properly be classed in the differential count. 
(Plate I.) 

2. Corpuscles about 12 to 15 fi in diameter, having a small, 
coarsely-meshed nucleus not exceeding 2 or 3 p. in diameter, and, 
as a rule, situated eccentrically. The nucleus stains greenish or 
quite black, and may or may not be separated from the proto- 
plasm by a colorless zone. The body of the cell is of round or 
ovoid shape, and stains a dull orange-yellow with shadings of a 
warm brown tint near the periphery and around the white peri- 
nuclear zone, if such exists. This form of cell appears to carry 
the same clinical significance as the normoblast, with which it 
may be grouped. (Plate I.) 



PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. 1 47 



In certain of the severe anemias, staining with 
Granular methylene-blue shows a peculiar granular condi- 
Degeneration. tion of the protoplasm in some of the erythro- 
cytes, attention first having been called to this 
fact by von Noorden, 1 who demonstrated the basophilic charac- 
ters of such granules, and described their occurrence in vari- 
ous pathological states. Many of the corpuscles thus affected 
are of the nucleated form, but non-nucleated cells may be simi- 
larly granulated ; as a rule, such corpuscles are also strikingly 
polychromatophilic. 

The granules appear either as fine or as coarse, stippled areas, 
staining intensely with the basic stain, and distributed through 
the body of the cell either quite uniformly, or in localized patches 
at one or at several points. In some cells they are exceed- 
ingly fine and closely packed together, so that at first glance the 
whole protoplasm appears to be a homogeneous mass of pur- 
plish discoloration ; in others the protoplasm is dotted here 
and there with coarse granules, not more than thirty or forty 
being found in the whole cell ; still others may contain both 
fine and coarse granules irregularly sprinkled over the surface. 
(Plate I.) 

The occurrence of somewhat similar granulations in the eryth- 
rocytes of the embryo has been noted by Engel, 2 Pappenheim, 3 
and others, who regard them as nuclear debris, the product of 
nuclear disintegration. Such an origin in embryonic blood is 
probably physiological. In post-uterine life, however, this proc- 
ess is to be regarded as a sign of stroma degeneration, arising 
in all likelihood through the influence of various blood-poisons. 
In some instances the change precedes all other recognizable al- 
terations in the blood, and appears as the first, and, indeed, some- 
times the only, distinct sign of anemia. 

Granular basophilia of the erythrocytes has been noted with more 
or less constancy in these conditions : pernicious anemia, leukemia, 
Hodgkin's disease, so-called tropical anemia, malarial fever, sepsis, 
carcinoma, long-standing suppurative lesions, and chronic lead-poi- 
soning. In chlorosis, if uncomplicated by symptoms of intestinal 
auto-intoxication, the erythrocytes do not exhibit this alteration ; 
granule cells are also absent in syphilis, in acute infectious diseases, 
in chronic lesions of the kidney and the liver, and in diabetes, ac- 
cording to Grawitz. 4 Regarding the occurrence of this change 

1 Charite-Annalen, 1892, vol. xvii., p. 202. 

2 Verhandl. d. Vereins f. innere Med. z. Berlin, 1898-99, vol. xviii., p. 216. 

3 Loc. cit. 

4 Am. Journ. of Med. Sc., 1900, vol. cxx., p. 277. 



I48 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 



in pernicious anemia, Ehrlich 1 believes that the number of gran- 
ule cells in the blood bears a certain relation to the severity of 
the disease, stating that they decrease and often disappear during 
the periods of remission, reappearing as the other blood changes 
again become evident. On the other hand, Litten, 2 who asserts 
that he has found these basophilic granulations in one-tenth of 
all cases of anemia, has been unable to determine their clinical 
significance from either a diagnostic or a prognostic point of view. 
The studies recently completed by Grawitz and Hamel 3 show 
that granular degeneration of the erythrocytes occurs with great 
regularity in saturnism, both in obscure and in well-marked cases, 
and these authors attach considerable diagnostic value to this fact, 
concluding that the sign is important in the diagnosis of lead- 
poisoning in patients in whom the intoxication is merely sus- 
pected, being evidenced by no other definite symptoms. 

Oligocythemia, or diminution in the number of 
Oligocy- erythrocytes below the normal standard, is pres- 
themia. ent to a more or less marked degree in all forms 
of anemia, being associated, naturally, with an 
oligochromemia, or diminution in the percentage of hemoglobin, 
but not necessarily with an oligemia, or reduction in the volume 
of the blood-mass. 

The loss of corpuscles may be slight or it may be marked, ac- 
cording to the nature of the anemia of which it is symptomatic. 
The most striking examples of oligocythemia are encountered 
after hemorrhages involving the loss of a large amount of blood, 
and in pernicious anemia; while in chlorosis, and in the majority 
of the secondaiy anemias the decrease is relatively less marked. 
The following summary of the averages of fifty consecutive 
counts each in cases of primary and secondary anemia, illustrates 
the various degrees of cellular loss which ordinarily accompany 
these conditions : 



It is impossible to designate the degree of oligocythemia which 
may exist without a fatal outcome, although a number of au- 
thorities have attempted to set fixed limits beyond which reduction 



Average of 50 counts. 



Erythrocytes per cb. mm. 



In pernicious anemia 

" leukemia 

" secondary anemia., 
" chlorosis 



1,152,470 
2,729,763 
3,642,900 
4,111,000 



1 Loc. cit. 

2 Deut. med. Woch., 1899, vol. xxv., p. 717. 

3 Deut. Archiv. f. klin. Med., 1900, vol. lxvii., p. 357. 



PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. 1 49 

in the number of erythrocytes is supposed to cause death. The 
effects of a blood loss are so diverse in different individuals that 
all such arbitrary rules must, of necessity, prove practically 
valueless. It should be remembered that while in some persons 
a comparatively moderate decrease may prove fatal, in others a 
most astonishing loss is compatible with life. It may be stated 
in general terms that few individuals recover in whom a count of 
less than 500,000 erythrocytes to the cubic millimeter is found, 
although occasional exceptions to this rule have been reported. 

Whether or not an actual, permanent polycy- 
Polycythemia. themia, or an increase in the number of erythro- 
cytes above the normal standard, exists is still 
an unsettled question, but the majority of authorities maintain 
that such a condition is due merely to some physical change 
producing concentration of the blood, or unequal distribution of 
the corpuscles, in favor of the peripheral blood-vessels. In health, 
it would not seem unreasonable to suppose that a moderate de- 
gree of polycythemia may be habitual in the strong, over-devel- 
oped adult, whose blood-making organs are possibly developed 
proportionately to the other parts of his system. In pathological 
conditions there is nothing tangible upon which to base the belief 
that an actual and permanent increase in the number of erythro- 
cytes ever takes place, the polycythemia associated with certain 
diseases being satisfactorily accounted for by coexisting physical 
conditions, in no way peculiar to the lesion in question. While 
it is true that in some conditions it is not always possible to ex- 
plain the increase by purely physical causes, still there is no posi- 
tive proof, in these instances, that the change is pathological. 
There seems, therefore, no evidence to warrant an arbitrary clas- 
sification of polycythemia into two divisions, actual and relative, 
as some authors have suggested. 

The cause of polycythemia, then, may be attributed to physio- 
logical factors such as concentration of the blood, peripheral 
stasis, increased viscidity of the erythrocytes, and their unequal 
distribution through the circulatory system. 

The polycythemia associated with various physiological and 
pathological conditions will be considered under their appropriate 
headings. Briefly, an increase of erythrocytes over the normal 
number is found in the following conditions : — 

1. In the new-born. 

2. After taking food. 

3. In starvation. 

4. During resort in high altitudes. 

5. From the effect of cold baths, massage, and electricity. 



150 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 



6. From the administration of lymphagogues, emetics, and 
purgatives. 

7. During active blood regeneration. 

8. During reformation of an exudate after aspiration. 

9. After urinary crises, diaphoresis, and emesis. 

10. In poisoning by illuminating-gas and by phosphorus. 

11. In Asiatic cholera, dysentery, and diarrhea. 

1 2. In acute yellow atrophy of the liver, and myxedema. 

13. In conditions of cyanosis and peripheral stasis, for example, 
uncompensated organic heart-disease, emphysema, and asphyxia. 

14. After the transfusion of blood. 

V. BLOOD PLAQUES. 

If a drop of fresh blood is examined microscopically, imme- 
diately after it has been taken from the body, a few pale, some- 
what spherical bodies, much smaller in size than the erythrocytes, 
may usually be observed. These bodies are known as the blood 
plaques or blood platelets. They are of homogeneous structure, 
either almost colorless or of a pale yellowish tint, spherical or 
irregularly ovoid in shape, and measure from 1 to 3 or 4 fi in 
diameter. They are non-nucleated, entirely devoid of ameboid 
movement, and react toward both basic and acid aniline dyes, 
having an amphophilic affinity. The plaques exist as free bod- 
ies in the general circulation, but directly after the withdrawal of 
the blood from the vessels they show a remarkable degree of vis- 
cosity, by virtue of which they tend to adhere in racemose masses 
the occurrence of which at or near the radiating points of the 
fibrin network has already been described. The old belief that 
the plaques represented a so-called " third corpuscle " of the 
blood is not justified, for it has been proved that these bodies are 
not distinct cellular entities, but rather debris, derived either from 
the blood corpuscles or from the plasma. Most authorities re- 
gard them as bits of globular matter extruded from the erythro- 
cytes, others as fragments of disintegrated nuclei of the leuco- 
cytes, and still others as masses of precipitated globulin. 

Exposure to the air appears to cause an almost immediate dis- 
appearance of the plaques from the blood, and, therefore, they are 
but seldom noticed in the blood-film prepared by the ordinary 
methods. To avoid bringing the blood in contact with the air, 
it may be drawn directly through a drop of Hayem's solution, or 
a weak solution of osmic acid, the mixture of the blood and 
fixative being then placed upon a slide, and examined in the usual 
manner. (See page 71.) 



HEMOCONIA. 



The number of plaques in normal blood varies within wide 
limits, according to the statements of different authorities, but 
about 300,000 to the cubic millimeter is generally considered the 
normal average, and from 180,000 to 500,000 the range under 
physiological circumstances. 

The plaques are generally increased in pernicious anemia, severe 
secondary a?iemias, leukemia, pneumonia, arthritis deformans, 
myelitis, tuberculosis, and bubonic plague, and diminished in hemo- 
philia, purpura, and acute febrile diseases such as erysipelas, ty pints 
fever, and the malarial fevers. 

VI. HEMOCONIA. 

Miiller 1 has called attention to the constant presence in normal 
and pathological blood of small, colorless, refractive bodies, of 
spheroidal or dumb-bell shape, not larger than 1 p. in diameter. 
These bodies, to which the terms hemoconia and blood-dust have 
been applied, are highly refractive, and possess active, limited 
molecular motility, but not true ameboid motion. They have 
been compared in appearance to fine fat-droplets, to micrococci, 
and to granules derived from the protoplasm of the leucocytes. 
Nothing is known of their histological character and significance, 
beyond the facts that they are not concerned in the process of 
fibrin-formation, and that they are not fatty bodies, since they are 
neither stained by osmic acid, nor dissolved by ether. Both 
Stokes and Wegefarth, 2 and Nicholls 3 regard them as free granules 
of the neutrophile and eosinophile leucocytes, and believe that 
they are probably concerned in the protective properties of the 
blood in immunity. Stengel 4 suggests that they may be simply 
the products of fragmentation of the erythrocytes, such as may 
be produced by heating fresh blood to destructive temperatures, 
when bits of the corpuscles are seen to bud out, break off, and 
float free in the plasma, endowed with pseudo-ameboid motility. 

Miiller found hemoconia numerous in a case of Addison's dis- 
ease, but these bodies were very scanty in a number of markedly 
cachectic conditions. Their occurrence in the blood appears to 
carry no definite clinical significance. 

1 Centralbl. f. Path. u. Bakteriol., 1896, vol. xxv., p. 529. 
2 Johns Hopkins Hosp. Bull., 1 897, vol. viii., p. 246. 
sPhila. Med. Journ., 1898, vol. L, p. 387. 
4 " Text-book of Pathology," Phila., 1899, 2d ed. 



SECTION IV. 



THE LEUCOCYTES. 



( Triacid Stain.) 

i, 2, 3, 4. Small Lymphocytes. 

Contrast the faintly colored protoplasm of these cells in the triple stained specimen 
with their intensely basic protoplasm in the film stained with eosin and methylene- 
blue, 17 and 18. The cell body of 1 is invisible. Note the kidney-shaped nucleus in 4. 

5, 6. Large Lymphocytes. 

With this stain the nucleus reacts more strongly than the protoplasm ; with eosin and 
methylene-blue (19, 20), on the contrary, the protoplasm is so deeply stained that the 
nucleus appears pale by contrast. This peculiarity is also observed in the smaller 
forms of lymphocytes. 

7, 8. Transitional Forms. 

Note the moderately basic and indented nucleus, and the almost hyaline non-granular 
protoplasm. Compare 8 with the myelocyte, 7, Plate IV, these cells differing chiefly 
in that the myelocyte contains neutrophile granules. 

9, 10, 11. Polynuclear Neutrophiles. 

These cells are characterized by a polymorphous or polynuclear nucleus, surrounded 
by a cell body filled with fine neutrophile granules. In 11 the nuclear structure is 
obviously separated into four parts ; in 9 it is moderately, and in 10 markedly, poly- 
morphous. 

12, 13. Eosinophiles. 

The nuclei are not unlike those of the polynuclear neutrophile, except that they are 
somewhat less convoluted, and poorer in chromatin, staining less intensely. The pro- 
toplasm is filled with coarse eosinophile granules, the characteristics of which are 
clearly illustrated by 13, a " fractured " eosinophile. 

14. Eosinophilic Myelocyte. 

Compare with 15. 

15, 16. Myelocytes. (Neutrophilic.) 

These cells are morphologically similar to 14, except that they contain neutrophile 
instead of eosinophile granules. Note that the granules of the myelocyte are identical 
with those of the polynuclear neutrophile. A dwarf form of myelocyte is represented 
by 16. 

(Eosin and Methylene-blue.) 

17, 18. Small Lymphocytes. 

Note the narrow rim of pseudo-granular basic protoplasm surrounding the nucleus, 

and the pale appearance of the latter. 
19, 20. Large Lymphocytes. 

Budding of the basic zone of protoplasm is represented by 20. Both of these cells 

belong to the same type as 5 and 6. 
21, 22. Large Mononuclear Leucocytes. 

Compared with 19 and 20, these cells have a decidedly less basic protoplasm, but a 

somewhat more basic nucleus. In the triple stained film these differences cannot be 

detected, so that they must be classed as large lymphocytes. 

23. Transitional Form. 

The distinction between this cell and 24 is not marked ; the nucleus of the latter 
simply being somewhat more basic and convoluted. 

24, 25, 26, 27. Polynuclear Neutrophiles. 

With this stain these cells show a feebly acid protoplasm, and lack granules. Note 
that the more twisted the nucleus the deeper it is stained. Compare with 9, 10, and 11. 
28, 29. Eosinophiles. 

Compare with 12 and 13. 

30. Eosinophilic Myelocyte. 

Compare with 14. 

31. Basophile. (Finely granular.) 

This cell is characterized by the presence ot exceedingly fine 6-granules, staining the 
pure color of the basic dye. The nucleus is markedly convoluted and deficient in 
chromatin. The cell here shown was found in normal blood. 
3 2 > 33) 34. 35, 3^- Mast Cells. 

The granules take a modified basic color, as shown by their royal-purple tint in this 
illustration. Note their unusually large size and ovoid shape in 35, their peculiar 
distribution in 35 and 36, and their irregularity in size in 32 and 36. With the triacid 
mixture these granules, as well as those of the finely granular basophile, 31, remain 
unstained, showing as dull-white stippled areas in the cell body. The nuclear chro- 
matin of the mast cell is so delicate and so feebly stained that it is barely visible. 
These cells were found in the blood of a case of spleno-medullary leukemia. 



Plate ii. 




The Leucocytes. 
(1-16, Tr i acid Stain ; 17-36, Eosin and Methylene-blue.) 
(E. F. Faber, fee.) 



SECTION IV. 
THE LEUCOCYTES. 

I. GENERAL CHARACTERISTICS. 

In the fresh, unstained blood-film the leuco- 
Appearance cytes are recognized as pale nucleated cells, the 
in majority of which are larger in size than the 

Fresh Blood, erythrocytes, by which they are greatly outnum- 
bered, the proportion of the former to the latter 
ranging approximately between I 1450 and 1 : 1,200 in normal 
blood. The size of the normal white corpuscles varies from 
about 7 fi to 10 or 12 fj. in diameter, and their shape, while in 
the resting stage, is irregularly round or oval. 

By careful examination four different varieties of these cells 
may be distinguished, the distinction between these forms being 
made more striking by the addition of a small quantity of a one 
per cent, acetic acid solution to the fresh film. These varieties, 
which are essentially the same as those first described by Schultze, 
in 1865, 1 are as follows : — (1) Non -ameboid cells about the size 
of the normal erythrocyte, consisting of a pale, compact, spher- 
ical nucleus, encircled by a narrow zone of homogeneous proto- 
plasm. (2) Ameboid cells almost twice the size of the erythro- 
cyte, consisting of a rather coarsely-meshed nucleus, spherical, 
ovoid, or indented in form, surrounded by a relatively large 
amount of clear protoplasm. The latter is highly opaque, for 
although it forms an exceedingly thin layer when spread out flat, 
it effectually obscures the outlines of objects over which it lies — 
as an explanation for which characteristic Kanthack and Hardy 2 
presume that the cell matter is composed of a colorless basis 
embedding immense numbers of minute vacuoles filled with a 
substance of a different refractive index. (3) Ameboid cells of 
slightly smaller size than the second variety, consisting of a single 
twisted nucleus, or of two or more separate round or ovoid nuclei 
embedded in a body of protoplasm crowded with exceedingly 
delicate, moderately refractive granules. The nuclear network is 
composed of chromatin threads closely united to form a compact, 
lobulated structure, and the protoplasm appears to consist of a 

^rchiv. f. mikr. Anat., 1865, vol. i., p. I. 
2 Journ. of Physiol., 1894-95, vol. xvii., p. 81. 



THE LEUCOCYTES. 



transparent substance, of gelatinous character, having a refractive 
index but slightly below that of the granules which it contains. 
(4) Ameboid cells containing a convoluted nucleus, or several 
spherical nuclei, embedded in a protoplasm filled with coarse, 
highly refractive, fat-like granules. The nuclear structure con- 
sists of a coarsely-meshed, knotted network, and the protoplasm 
is much less refractive than its granules, being clear and struc- 
tureless in appearance. 

Spontaneous changes in the shape of the larger 
Ameboid varieties of leucocytes may be observed if the slide 
Movement, is placed upon a warm stage having a temper- 
ature of about 98. 5 0 F. During these ameboid 
movements the shape of the cells constantly undergoes alteration, 
by the alternate contraction and expansion of the protoplasm. 
Tentacular processes reach out from various portions of the 
cell body, while at other points its surface becomes retracted, 
so that it may appear as an irregular nucleated mass provided 
with one or more long, snake-like arms projecting from a 
central body. These ameboid cells are chiefly concerned in 
the process of phagocytosis, or the engulfing and destruction of 
micro-organisms and other foreign matter which may gain en- 
trance into the circulating blood, and to leucocytes which 
exert this function the term phagocyte has been applied. The 
well-known experiments of Metschnikoff 1 have shown their 
propensity for seizing upon and devouring pathogenic bacteria 
such as the anthrax bacillus and the erysipelas streptococcus, 
and further proof of such phagocytic action may be frequently 
found in the fragments of other foreign matter, such as bits 
of old blood clots and malarial pigment, embedded in their 
protoplasm. 

It has also been suggested by Gabritschewsky 2 that it may be 
possible under some circumstances that phagocytes are capable 
not only of engulfing solid bodies, but may also imbibe and ab- 
sorb liquid substances, which are thus rendered harmless to the 
organism, and to this property the term pinocytosis has been 
given by this author. 

The ameboid property of the leucocytes is also responsible for 
the ease with which these cells escape from the blood-vessels into 
the perivascular tissues in inflammatory lesions, and to a less ex- 
tent in health. This well-known process of diapedesis is facili- 
tated by virtue of the leucocyte's ability to elongate and flatten 

1 " L' Inflammation," Paris, 1892. 

2 Annal. de l'lnstitut Pasteur, 1894, vol. viii., p. 673. 



GENERAL CHARACTERISTICS. 



157 



out so that it may readily emigrate through the spaces between 
the endothelial cells of the vessel-wall. 

The identification of the various forms of leuco- 
Cell cytes depends largely upon the presence or ab- 
Granules. sence of granules in their protoplasm, and upon 
the distinctive manner in which these granules 
react towards the acid, basic, and so-called neutral solutions of 
the aniline dyes. By means of this method of " color-analysis " 
Ehrlich has provided a rational means by which the study of the 
leucocytes may be undertaken. 

Five varieties of granules, which are designated by the use of 
the Greek letters a, fi, y, 0, and e, may be recognized in the cell- 
bodies of the leucocytes, as follows : — 

1. a-grantiies (eosinophile, oxyphile, or coarse oxyphile gran- 
ules). Coarse, spherical or ovoid, highly-refractive granules of 
a peculiar fat-like appearance, showing a striking affinity for acid 
stains, especially for eosin. In normal blood they occur only in 
leucocytes with polynuclear or polymorphous nuclei, but in cer- 
tain pathological conditions they may be found in that variety of 
the leucocyte known as the eosinophilic myelocyte. 

2. fi-gi'anules (amphophile granules). Fine granules which 
are capable of reacting toward both acid and basic dyes, inva- 
riably staining with the former and sometimes with the latter, if 
the stains are used singly, while in a mixture of the two they 
always react toward the acid dye. These granules never occur 
in normal blood, but in some pathological conditions a varying 
proportion of the leucocytes may exhibit amphophilic reactions 
on the part of some of their granules. 

3. j-granules (mast-cell, or coarse basophile granules). Very 
coarse granules, measuring from .2 to .4/1 in diameter, and pos- 
sessing an intense affinity for basic dyes. If stained with car- 
boltoluidin-blue, with thionin, or with alkaline methylene-blue, 
and differentiated with glycerine-ether, they are colored a dis- 
tinctive deep purplish-red. These granules occur in a form of 
leucocyte known as the mast- cell, only in certain rarely observed 
pathological states. 

4. o-granules (fine basophile granules). Fine granules, stain- 
ing with basic dyes, and occurring under normal conditions in 
leucocytes having polymorphous nuclei. They are most clearly 
demonstrated with such basic dyes as thionin or methylene-blue, 
by which they are stained a deep blue color. 

5. i-granules (neutrophile, or fine oxyphile granules). Ex- 
ceedingly fine granules, formerly thought to have a selective 
affinity for the neutral element of a solution composed of acid 



158 



THE LEUCOCYTES. 



and basic dyes, but now known to have, in reality, a feeble oxy- 
philic tendency. They occur abundantly in the normal polynu- 
clear neutrophile cells, and also in several pathological forms of 
leucocytes : the myelocyte, the small mononuclear neutrophile, 
and the "small neutrophilic pseudolymphocyte." 

But little is known of the real nature and function of the leuco- 
cyte granules, in spite of their elaborate study by different in- 
vestigators. Two leading views, which excite much controversy, 
to-day command attention : the hypothesis of Ehrlich, 1 and the 
bioblastic theory of Altmann. 2 Ehrlich regards them as an 
evidence of a specific secretory function on the part of the 
cells, which under normal conditions contain but a single variety 
of granules. They are to be considered as products of cellular 
metabolic activity, and are destined to be given off in the vicinity 
of the cells, this elimination perhaps constituting one of the most 
important functions of the latter. Far from representing mere 
waste-products, as some authors contend, they are in reality ele- 
ments of decided, although obscurely-defined, value to the or- 
ganism. Altmann, in his bioblastic theory, considers cell granules 
as definite biological entities, and believes that they " serve as a 
basis for the explanation of the many phenomena of organic met- 
abolism." In summing up their functions, he remarks that "they 
effect through oxygen-transmission both reductions and oxygena- 
tion, and in this manner accomplish the disunions and the synthe- 
ses of the economy without sacrificing their own individuality." 

As a rule, the cell granules are thought to be relatively simple 
bodies, although their exact composition is as yet undeter- 
mined. It has been proved by Weiss 3 and others that they are 
of albuminous character. The eosinophile granules, in which 
iron has been demonstrated by Barker 4 and other observers, are 
more complex than the other varieties. They are of a higher 
histological structure, consisting of an external limiting portion 
which may be clearly differentiated from the central area. Han- 
kin and Kanthack 5 have determined the fact that increased bac- 
tericidal power of the blood is closely correlated with the dis- 
charge of both eosinophile and neutrophile granules into the 
plasma, and the former observer 6 has furthermore shown that in 

1 Loc. cit. 

2 " Uber die Elementarorganismen und ihre Beziehungen zu den Zellen," Leipzig, 
1894, 2d ed. 

3 " Hematologische Untersuchungen," Wien, etc., 1896. 
4 Johns Hopkins Hosp. Bull., 1894, vol. v., p. 93. 

5 Centralbl. f. Bakt. u. Par., 1892, vol. xii., p. 777. Ibid., 1893, vol. xiv., p. 

852. 

6 Journ. of Physiol., 1894-95, vol. xvii., p. 81. 



CLASSIFICATION. 



159 



experimental infections there is at the point of the infection an 
accumulation of cells containing eosinophile granules, together 
with a discharge of such granules during the conflict of the cells 
with the invading micro-organisms. 

In the normal adult the number of leucocytes 
Normal Num- in the peripheral circulation averages from about 
ber. 5,000 to 10,000 to the cubic millimeter of blood. 

In the majority of instances, in which the influ- 
ences of physical factors are excluded, a count of 7,500 leu- 
cocytes per cubic millimeter may be regarded as the mean nor- 
mal average. Variations of several thousand cells per cubic 
millimeter above and below this number are within physiolog- 
ical limits, and frequently occur because of the extreme suscep- 
tibility of the leucocytes to agencies causing such transient fluctu- 
ations. The following table, compiled from data given by Hayem, 1 
Grawitz, 2 and von Limbeck, 1 shows the average number of leuco- 
cytes determined by various authorities : 



Thoma 8,687 P er CD - mm. 

Von Limbeck 8,500 

Rieder • 7,680 

Boeckman ; Halla 7,533 

Graeber; Reinecke 7,242 

Tumas 6,200 

Hayem 6,000 

Average 7, 40 6 



II. CLASSIFICATION. 

Six distinct varieties of leucocytes may be recognized in the 
healthy adult's blood stained by the triacid mixture of Ehrlich, 
according to the method described in a previous section. These 
varieties, together with their normal relative percentages and abso- 
lute number to the cubic millimeter of blood, are as follows : — 

Variety. Per cent. Number per cb. mm. 

Small lymphocytes 20-30 1,000-3,000 

Large lymphocytes and tran- 
sitional forms 4-8 200-800 

Polynuclear neutrophiles 60-75 3> 00 °-7>5 00 

Eosinophiles °-5~5 2 5-5°° 

Basophiles, as high as 0.5 25 



1 Loc. cit. 

2 "Klinische Pathologie des Blutes," Berlin, 1896. 



i6o 



THE LEUCOCYTES. 



The variations in these numbers and percentages, which de- 
pend upon different physiological and pathological influences, are 
referred to in other sections. 

The lymphocytes, or small lymphocytes, as 
Small they are commonly designated in contradistinction 
Lymphocytes, to the large mononuclear forms, are non-granu- 
lar cells which measure from about 5 to 10 /j. in 
diameter, their average size being that of the normal erythrocyte, 
or 7.5 /j. in diameter. The typical cell of this class consists of a 
single, round, deeply staining nucleus surrounded by a narrow 
zone of protoplasm, and sometimes provided with one or two 
pseudo-nucleoli, situated eccentrically upon the nuclear surface. 
The nucleus is so relatively large that it almost completely fills 
the cell, being its most conspicuous part, while the rim of proto- 
plasm is usually so narrow and poorly defined that at first glance 
it may escape notice. These characteristics — a relatively large 
nucleus, and a relatively scanty amount of protoplasm — are more 
conspicuously exhibited in the smaller than in the larger forms 
of these cells. 

With Ehrlich's triple stain the nucleus, being rich in chromatin, 
is colored deep blue or purple, and the protoplasm is either en- 
tirely unstained, appearing as a narrow hyaline halo surrounding 
the nucleus, or it is tinged a delicate shade of pink, if it happens 
to react toward the acid fuchsin of the mixture. 

In films stained with eosin and methylene-blue the nucleus 
shows a decided affinity for the basic dye, usually staining dark 
blue, or, more rarely, pale green. The protoplasm shows as a 
relatively narrow encircling area of deep blue color, which has 
been likened in appearance to the surface of ground glass ; it is 
much more intensely basic than the nucleus, which looks pale by 
contrast. 

Occasionally small lymphocytes are encountered in which the 
nucleus is atypical both in morphology and in staining properties. 
Thus, some cells contain a pale, almost hyaline nucleus composed 
of an exceedingly scanty chromatin structure which reacts very 
feebly to the basic dyes ; others contain a deeply stained, indented 
or kidney-shaped nucleus similar in shape to that of the so-called 
" transitional " forms; while still others are provided with a 
nucleus which has evidently become completely divided, so that 
such a cell really contains two distinct hemispherical nuclei, rich 
in chromatin, deeply stained, and situated toward the poles of 
the cell body. These irregular forms of lymphocytes occur in 
both normal and in pathological blood, but with much greater 
frequency in the latter, especially in both forms of leukemia. 



CLASSIFICATION. 



161 



Under this term it is convenient to include 
Large both the larger forms of the true lymphocyte — 
Lymphocytes, those measuring 1 1 fi or more in diameter — and 
also that variety of hyaline cell known as the 
large mononuclear leucocyte. These two forms of cells, although 
they are generally considered as distinct histological species, one 
being a true lymphocyte and the other probably a marrow-bred 
element, may for practical purposes be classed together, since it 
is impossible to differentiate one from the other in the specimen 
prepared for an ordinary clinical examination. 1 

Cells of this type may range in size from 1 1 to 1 5 fi or even 
larger in diameter, and are usually of round or ovoid shape, ex- 
cept in an occasional cell where, in consequence of the injury 
received during the preparation of the blood-film, the outline 
may be exceedingly irregular and deformed. The nucleus, which 
is round, ovoid, or somewhat elongated, is generally situated to- 
ward the periphery of the cell body. In most of the cells the 
amount of protoplasm is relatively greater than that of the small 
lymphocyte, but occasionally this peculiarity cannot be dis- 
tinguished. 

The nucleus, being poor in chromatin, stains pale blue with the 
triple stain, and is usually so delicately tinted that it is almost 
invisible ; the protoplasm is faintly tinged with pink, or with gray- 
ish-blue, or it may remain practically colorless, showing merely 
as an indefinite hyaline area surrounding the nucleus. 

With mixtures of a strong acid and basic dye, such as eosin 
and methylene-blue, the nuclear chromatin stains a diffuse sky- 
blue tint, and the protoplasm exhibits a more or less decided af- 
finity for the basic element of the staining fluid. This tendency 
is very marked in some cells, the protoplasm of which contains 
an intensely basic pseudo-granular zone staining much deeper 
blue than the rest of the cell body, paralleling the extreme periph- 
ery of the cell, and often apparently separated from the nucleus 
by a distinct unstained area. In other cells this basic affinity is 
not so conspicuous, their protoplasm staining a diffuse purplish 
shade in which a rose-red tone prevails. 

1 Some authors, Ehrlich himself among them, maintain that a distinction be- 
tween these two forms of cells may invariably be made in the stained specimen. 
Thus, in the film stained with methylene-blue, it is held that the true lymphocyte, no 
matter what its size, always possesses a strongly basic protoplasm and nucleus, the 
latter staining less deeply than the former ; while the large mononuclear leucocyte 
has a feebly basic protoplasm and nucleus, the latter staining more intensely than the 
former. These points of difference, although they may be distinguished in specimens 
stained by special methods, seem to be too finely drawn to justify their acceptance as 
reliable criteria for the identification of these two groups of cells in films prepared by 
the technique adapted to routine clinical work. 

11 



l62 



THE LEUCOCYTES. 



Apparent extrusion of portions of the cell body is not uncom- 
monly observed, this phenomenon producing a peculiar "frayed- 
out," ragged appearance around the periphery of the lympho- 
cyte, due to the partial detachment of small bits of the peripheral 
seam of basic protoplasm, which loosely adhere to the outer 
margin of the cell. Occasionally these small basic masses be- 
come entirely detached, and may be seen lying free in the plasma, 
alongside the cell of which they were once a part. 

Typical forms of the large and small lymphocyte, such as are 
seen in the great majority of stained blood-films, may be dis- 
tinguished without difficulty, but in some diseases, notably in the 
lymphatic variety of leukemia, irregular forms of these cells are 
found, the size and nuclear characteristics of which are so confus- 
ingly atypical that it is sometimes futile to attempt the classification 
of such hybrids into two arbitrary groups, large and small. Thus 
one may meet with cells the size of the small lymphocyte but hav- 
ing a feebly basic, eccentric nucleus and a relatively large amount 
of protoplasm ; and with cells identical with the large lymphocyte 
except that they possess a small, spherical, strongly basic nucleus. 
In attempting to differentiate these atypical forms in the triple 
stained specimen, it is safe to be guided by the suggestions given 
by Thayer, 1 who is inclined to place more emphasis upon the 
character of the nucleus than upon the size of the cell body as a 
whole. Thus, in a doubtful mononuclear, non-granular cell in 
which the nucleus is similar in size and shape to that of the small 
lymphocyte, regardless of its affinity for the basic element of the 
stain, the cell is classed as a small lymphocyte, until the size of 
such a cell exceeds that of the polynuclear neutrophile. Some 
cells no larger than the smallest lymphocyte may be classed as 
large lymphocytes if their nuclei are decidedly ovoid in shape, 
and pale in color. In spite of every precaution, however, 
it must be admitted that in some instances differential counts 
of these two types of cells must be more or less inaccurate, 
for the obvious reason that so much depends upon the personal 
equation. 

The so-called transitional forms are cells which 
Transitional closely resemble the large lymphocyte in shape 
Forms. and in size, but which differ from the latter variety 
of cell chiefly in having a nucleus which, instead 
of being ovoid in shape, is indented and drawn out into the form 
of a crescent with rounded poles, the concave aspect of the nu- 
clear figure lying toward the center of the cell. In other forms 
the nucleus may have become moulded into a figure resembling 

1 Johns Hopkins Hosp. Reports, 1894, vol. iv.,p. 103. 



CLASSIFICATION. 



163 



an hour-glass, which occupies the central portion of the cell 
body, not lying in contact with its periphery at any point. 

With the triple stain the nucleus of this cell is usually stained 
somewhat darker blue than that of the large lymphocyte, and 
the protoplasm is either quite colorless, or, perhaps, slightly 
tinged a grayish-blue. With eosin and methylene-blue the nu- 
cleus shows a moderately strong affinity for the basic dye, being 
colored much darker blue than the nucleus of the large, but dis- 
tinctly paler than that of the small, lymphocyte ; the protoplasm 
is stained a diffuse purplish tint, in which the pink tinge of the 
eosin conspicuously predominates. 

Inasmuch as the clinical significance of the transitional forms 
is identical with that of the large lymphocytes, it is customary to 
class both forms together under a single heading, in the per- 
centage table of the different forms of leucocytes 

Polynuclear neutrophils are cells which, as a 
Polynuclear general rule, measure from about 10 to 12 11 in 
Neutrophiles. diameter, although their size may vary within 
wide limits, some being not much larger than 
the small lymphocytes, while others are nearly twice this size. 
The distinguishing characteristics of these cells are the twisted, 
polymorphous nature of the nuclei and the so-called " neutro- 
philic " reaction of the granules which are embedded in the pro- 
toplasm. The nucleus may be of almost any shape — elongated, 
wreathed, lobulated, horseshoe-shaped, or twisted into designs re- 
sembling various letters of the alphabet, such as an S, Z, U, or 
E. It usually consists of several apparently separate masses of 
irregular shape connected with each other by delicate filamentous 
strands of chromatin, which dip beneath the surface of the pro- 
toplasm, and, owing to the density of the overlying granules, are 
invisible or but dimly denned in the triple stained specimen. 
By the use of the simpler double stains, such as eosin and 
methylene-blue, the presence of these connecting chromatin 
threads may be demonstrated with great clearness. Less com- 
monly, a cell contains several small oval or round nuclei, which 
are actually separated from each other, complete division at the 
points of constriction having resulted in the production of two or 
three, and, in rarer instances, even six or seven distinct nuclei. 
The nuclear structure is rich in chromatin, which forms a dense, 
unevenly staining network possessing a marked affinity for the 
various basic dyes. It stains dark blue or greenish-blue with the 
triple stain, and still more intensely blue with eosin and methyl- 
ene-blue solutions. 

The fact that the single, twisted type of nucleus predominates 



164 



THE LEUCOCYTES. 



in these cells has led to the current use of the adjective " poly- 
morphonuclear " as a substitute for " polynuclear," but it is per- 
fectly obvious that both terms may be used synonymously, the 
latter perhaps being preferable, because of its brevity, and of its 
established vogue. The irregularity of the nucleus is regarded 
as a sign of the ameboid activity of the cell, as first suggested by 
Arnold, 1 and not as an indication of degeneration, as formerly 
believed. It has been effectually demonstrated by Sherrington 2 
that if such cells are allowed to quiet down before they are killed, 
their nuclei usually return to a spheroidal form. 

The protoplasm of the polynuclear leucocyte is densely packed 
with exceedingly fine so-called neutrophile granules, which 
stain lavender, or purple, or, rarely, pink, with Ehrlich's triacid 
mixture, but which are usually unstained by solutions containing 
eosin and methylene-blue. Kanthack and Hardy 3 have shown 
that these granules have "a minimal attraction for acid dyes, or, 
briefly, a minimal oxyphile reaction," and, furthermore, that 
Ehrlich's neutral mixture by which they are intensely stained, is 
not, chemically speaking, a neutral stain, but, on the contrary, a 
powerful and exceedingly differential acid dye, intensely staining 
oxyphile granules of all varieties. 4 The oxyphilic tendency of 
the granules may be beautifully demonstrated by the use of 
Jenner's eosin-methylene-blue formula, to which reference has 
been made. Thus, having proved that the granules of the poly- 
nuclear " neutrophile " cell of Ehrlich display a distinct, although 
feeble, affinity for acid dyes, and that they are unstained by basic 
and neutral dyes, the term "finely granular oxyphile cell" has 
been adopted by these authors for this variety of leucocyte, the 
granules being known as " finely granular oxyphile " granules. 
It is doubtful, however, if the use of these unwieldy terms will 
receive general approval, except by certain of the British school. 
To designate a polynuclear leucocyte as a " finely granular oxy- 
phile cell" is even more glaringly inappropriate than the use of 
Ehrlich's term, "neutrophile," for other varieties of leucocytes 

^rchiv. f. Mikroskop. Anat., 1887, vol. xxx., p. 226. 
2 Proc. Internat. Congress of Physiologists, Liege, 1892. 
3 Journ. of Physiology, 1894, vol. xvii., p. 61. 

4 Reasoning upon the basis that eosin stains with most striking intensity in an 
aqueous solution, less decidedly in a glycerin solution, and even less strongly when 
dissolved in strong alcohol, these investigators distinguish three classes of oxyphile 
granules, according to the intensity of their affinity for acid dyes, thus : (i) Those 
which stain with eosin only in aqueous solutions, or in alcoholic solutions of a per- 
centage below 60 ; (2) those which stain in both aqueous and glycerin solutions, 
but not in a strong alcoholic solution (90 to 95 per cent. ) of the dye, and (3) those 
which stain with aqueous, glycerin, and strong alcoholic solutions. They include 
in the first class, the neutrophile and the amphophile granules of Ehrlich. 



CLASSIFICATION. 



165 



(z. e., myelocytes, and " neutrophilic pseudolymphocytes ") may 
be just as fittingly described by the former phrase. 

The granules are of very small size, and of irregular wedge - 
or spike-shape, never being spherical or ovoid in contour. They 
are usually most densely distributed about the periphery of the 
cell, whence they gradually shade off toward the nucleus, which 
is frequently found to be encircled by a perfectly hyaline, non- 
granular zone. The granules are not always confined to the cell 
protoplasm, being scattered over the nucleus, portions of which 
even may be partly obscured by the overlying granular film: 

The jelly-like substance of the protoplasm in which the granules 
are embedded appears to show a slight affinity for acid dyes, the 
intensity of this affinity varying greatly in different cells. With 
the triple stain this reaction is evidenced by the variable depth 
of fuchsin-colored undertone which may be detected beneath the 
purplish color of the granules ; while in the specimen stained 
with eosin and methylene-blue, in which the granules are not 
visible, the protoplasm is evenly tinted the color of eosin. 

These cells are the most conspicuous of all the 
Eosinophiles. leucocytes, and may be at once identified by the 
presence of a more or less polymorphous nucleus 
embedded in a protoplasm studded with coarse, highly refractive 
granules which have a strong affinity for acid dyes, such as eosin 
and acid fuchsin. Owing to the large size of their granules, and 
to their striking oxyphilic reaction, these cells are also known by 
the term "coarsely granular oxyphile cells," in contradistinction 
to the "finely granular oxyphile cells," or polynuclear leucocytes. 
(Kanthack and Hardy.) The size of the eosinophile varies very 
greatly, but most of them approximate the size of the polynuclear 
neutrophile, or are, perhaps, a trifle smaller. Their diameter 
commonly ranges from 8 to 1 1 fx, although occasionally forms 
not larger than the normal erythrocyte are to be observed. Their 
shape is usually that of an irregular sphere, or oval. 

The nucleus may be kidney- or horseshoe-shaped, or twisted 
and drawn out into an irregular mass, but it is rarely as con- 
stricted and deformed as that of the polynuclear neutrophile. It 
is nearly always situated eccentrically, cells of this variety with 
centrally placed nuclei being veiy uncommonly seen. Occasion- 
ally the eosinophile contains multiple nuclei, consisting of sev- 
eral oval or round masses between which no connecting chro- 
matin threads can be distinguished, but usually such portions 
of the nucleus are joined together by extensions of chromatin 
running beneath the protoplasm. The nucleus stains faintly in 
comparison with that of the polynuclear neutrophile, although 



i66 



THE LEUCOCYTES. 



more intensely than that of the large mononuclear cell ; it is col- 
ored pale blue or greenish-blue by the triple stain, and dark blue 
by eosin and methylene -blue mixtures. 

The granules, which are relatively large in size and quite regu- 
larly spherical in shape (in contrast to the delicate, irregularly 
shaped granules of the polynuclear neutrophile), react strongly 
toward the acid elements of the triple stain ; some are stained 
a brilliant fuchsin color, some deep red, while others are brown- 
ish-yellow, or copper color, or even black ; with mixtures of 
eosin and methylene-blue they take the brilliant color of eosin. 
There appears to be a marked tendency on the part of the gran- 
ules to overrun the nucleus, so that its morphology in some cells 
is almost indistinguishable. The granules are also prone to be- 
come readily detached from the protoplasm, which doubtless ac- 
counts for their uneven, blotchy distribution in many cells, in 
which densely packed granular areas alternate with open spaces 
merely punctuated here and there with an occasional granule. 

Eosinophiles appear to offer but feeble powers of resistance 
against external influences, so that it is common to find these 
cells so injured by the process of making the film, that the nu- 
cleus has escaped from the cell body, and the granules, lying 
free in the plasma, are scattered about it in a cloud. This insta- 
bility, or " explosive" character of the eosinophile is one of its 
most striking attributes, for, while observed now and then in a 
polynuclear neutrophile, it occurs with much greater frequency 
in eosinophiles than in the latter type of leucocyte. 

The protoplasm of the cell may or may not show an affinity for 
the aniline dyes ; usually it does not, so that the granules appear 
to be embedded in a perfectly hyaline substance ; occasionally 
it is faintly stained by fuchsin, or by eosin. 

Finely granular basophile cells, containing Ehr- 

Basophile lich's o-granules, are occasionally encountered in 
Cells. normal blood, but with such rarity that their real 
significance is not understood. 

In general morphology and size these cells resemble the poly- 
nuclear neutrophiles. The nucleus is invariably twisted, and usu- 
ally consists of two or three distinct lobes joined by thin chro- 
matin bands ; in the stained specimen it is never of round or oval 
shape, but always shows evidences of polymorphism. The nuclear 
structure is composed of a delicate, scanty network of chromatin, 
and has a moderate affinity for basic dyes, staining dull blue with 
the triple stain, and pale sea-green with eosin and methylene-blue 
mixtures. 

The protoplasm of the cell is closely packed with fine, irregu- 
larly shaped granules having an intensely basic reaction ; they 



CLASSIFICATION. 



167 



stain deep blue with solutions containing methylene-blue, but are 
not colored by the triple stain, showing in films stained with 
this mixture as groups of dull white spots scattered through the 
cell body. Jenner's stain is most useful in bringing out the char- 
acteristics of these granules. 

Myelocytes, or marrow cells, are relatively 
Myelocytes, large round or oval cells, ranging from 10 to 20 
fij or even more in diameter, their average size 
being somewhat larger than that of the large lymphocyte, which 
they resemble in general morphology. The nucleus of the typ- 
ical myelocyte is of spherical or ovoid shape, and is situated 
eccentrically, lying distinctly toward one side of the cell, so that 
the peripheries of both cell and nucleus are often closely ad- 
jacent for some little distance — usually for from one-third to 
one-half of their course. The nucleus reacts feebly toward the 
basic element of the triple stain, being colored a pale, delicate 
sky-blue with this solution ; it stains a moderately deep blue or 
purple with eosin and methylene-blue mixtures, and appears to 
be more coarsely netted and deeply stained than in films prepared 
by the preceding method. 

In the smaller forms of myelocytes the nucleus is frequently 
found to occupy the center of the cell body, so that it is sur- 
rounded on all sides by a protoplasmic zone of even width. In 
some of the larger forms the nucleus may be indented, and 
moulded along one margin of the cell body like that of the so- 
called " transitional " leucocyte. In rare instances actual division 
of the nucleus appears to have occurred, so that two separate 
nuclei, each shaped like a flattened hemisphere and situated at an 
extreme pole of the cell, may be found. Such cells are often 
mistaken at first glance for polynuclear neutrophiles, inasmuch as 
both forms of cells contain multiple nuclei and neutrophile gran- 
ules ; but the nucleus of the polynuclear neutrophile is always 
more or less twisted and of undulating surface, relatively rich in 
chromatin and stained with decided intensity, and rarely situated 
at the poles of the cell, while the nuclear halves of this type of 
the myelocyte are of regular outline and uniformly close to the 
surface of the cell, relatively poor in chromatin and faintly 
stained, and invariably occupy the extreme poles of the cell bod}'. 

The protoplasm of the myelocyte is filled with fine neutrophile 
granules, such as occur in the polynuclear neutrophile ; they are 
most densely distributed at the periphery', and grow appreciably 
less abundant as they approach the nucleus, which they may 
overrun, spreading over its surface like a thin veil, so that its 
structure is more or less hidden. 



THE LEUCOCYTES. 



This one characteristic — the presence of neutrophile granules 
in the protoplasm — at once serves to distinguish the myelocyte 
from the large lymphocyte, which it may exactly resemble in 
size, shape, and nuclear structure ; the importance of using Ehr- 
lich's triple stain to differentiate these granules in specimens used 
for differential counting is therefore patent. 

With the triple stain, the granules stain purple or lavender, 
exactly like those of the polynuclear neutrophile. With eosin 
and methylene-blue mixtures the protoplasm is stained light pur- 
ple, broken here and there by indistinct, darker granular areas of 
the same color, indicating the presence of basophile granules, in 
addition to those of neutrophile reaction, which are not clearly 
demonstrable with this stain. 

In certain pathological conditions, notably in spleno-medullary 
leukemia, an occasional myelocyte may be observed which con- 
tains both fine neutrophile and very coarse basophile granules, 
the latter being precisely identical in size, shape, and tinctorial 
qualities with Ehrlich's y or mastzellen granules. They are 
situated both in the protoplasm of the cell, and over the nucleus. 
These granules are, in the author's experience, demonstrable only 
in specimens stained by Jenner's method showing in such prep- 
arations as coarse, brilliant purple granules contrasting vividly 
with the paler eosin-colored neutrophile granules which fill the 
body of the cell, and with the greenish-blue color of the nucleus. 

Eosinophilic myelocytes, or myelocytes with a protoplasm filled 
with coarse eosinophile instead of neutrophile granules, are 
common to several pathological conditions, but occur with es- 
pecial frequency in the spleno-medullary variety of leukemia, and 
also in pernicious anemia, to some extent. Such cells are iden- 
tical in size and morphology of cell body and nucleus with the 
commoner neutrophilic myelocytes, from which they differ only 
in containing eosinophile granules. 

The normal habitat of the myelocyte is in the red bone mar- 
row, and its presence in the circulating blood must always be re- 
garded as pathological. At one time regarded as practically 
pathognomonic of leukemia, the myelocyte is now known to occur 
in many other conditions, especially those characterized by pro- 
found cachexia, by marked anemia, and by increase in the num- 
ber of leucocytes. The occurrence of myelocytes in the blood 
in various diseases, and the clinical significance of these cells is 
discussed in another place. (See " Myelemia.") 

Cells containing Ehrlich's ^-granules, known 

Mast Cells, by the term mastzellen, or mast cells, are oc- 
casionally present in the peripheral circulation 



CLASSIFICATION. 



169 



as the result of certain pathological influences, but are totally 
foreign to the normal blood of man. They are very commonly 
found, sometimes in considerable numbers, in the spleno-medul- 
lary type of leukemia, but are by no means invariably associated 
with this disease, being absent in many typical cases. 

The cells are of spherical or ovoid shape, and are characterized 
by a relatively large, structureless nucleus enclosed in an almost 
indefinable protoplasm, and by the presence of coarse basophile 
granules scattered irregularly over the surface of the cell — marks 
of identification which remain unchanged whatever the size of 
the cell may be. No variety of cell found in the blood exhibits 
wider ranges in size. The forms most commonly observed meas- 
ure approximately from 9 to 12 ju in diameter ; some have a di- 
ameter of fully 20 or even 22 //, but cells of this extremely large 
size are the exception rather than the rule ; others are scarcely 
larger than the small lymphocyte, being but 7 or 8 ft in diameter, 
and these very small forms are also uncommon. 

The nucleus is round, oval, or somewhat lobulated, and occu- 
pies the greater part of the cell body, in which it is usually situ- 
ated eccentrically. Owing to the similarity in the appearance of 
the nucleus and the protoplasm, it is frequently impossible to de- 
termine the precise point at which the former structure begins 
and the latter ends, so that, in the stained specimen, many cells 
are met with which appear to consist simply of irregular groups 
of granules clinging to a pale nucleus, every definite trace of the 
cell body being lost. (See Plate II, Figs. 35 and 36.) In films 
stained with Jenner's solution (which is, by far, the most satisfac- 
tory stain for illustrating the finer morphology of these cells) the 
nucleus is colored a beautiful, iridescent greenish-blue, the tint of 
which is so extremely delicate that in many cells it is barely per- 
ceptible. The staining, though faint, is even and clear, indicating 
a structure almost totally devoid of chromatin. 

The granules are invariably large and coarse, and vary greatly 
in size and in shape. Some are smaller than the granules of the 
eosinophile cell, while others approach or even slightly exceed 
. 5 p. in diameter. They may be spherical, egg-shaped, or roughly 
cuboid, the latter form of granule being exceedingly common. 
A single type of granules is not always found to the exclusion of 
the others, for one cell often contains granules of every possible 
variety of shape and size ; this peculiarity is especially striking 
in some of the smaller forms of cells in which extremely coarse 
egg-shaped and smaller spherical granules may be distinguished 
clinging to the periphery of the nucleus about which no evidence 
of protoplasm is demonstrable. (See Fig. 36, Plate II.) In other 



170 



THE LEUCOCYTES. 



forms, both large and small, the large spherical or ovoid granules 
may prevail almost exclusively. (See Figs. 33, 34, and 35, Plate 
II.) The distribution of the granules through the cell follows no 
constant rule, but it is evident that a more or less decided tendency 
exists toward their collection near the periphery. They are al- 
ways most densely distributed at this point, sometimes extending 
inward over the nucleus which is thus partly hidden, and some- 
times crowded into a limited zone which coincides with the outer 
boundary of the cell for the greater part of its extent. 

The granules of the mast cell show an intense affinity for basic 
aniline dyes, toward which they react metachromatically, in a 
highly characteristic manner. With Jenner's solution they are 
stained a deep royal purple color in which the red tone is dis- 
tinctly evident, thus differing from the granules of other basophile 
cells which are stained a pure blue with this mixture. Dr. H. F. 
Harris has called the writer's attention to a still more distinctive 
method of identifying these granules, by first staining with carbol- 
toluidin-blue or with thionin, and then by differentiating with 
Unna's glycerin-ether mixture. In specimens thus treated the 
mast cell granules are of a dark red color, while other basophile 
granules stain blue, so that the former must be regarded as hav- 
ing a modified basic reaction. They are stained reddish-violet 
with Ehrlich's acid dahlia solution, and deep blue with aqueous 
solutions of methylene-blue. They are not stained by the tri- 
acid mixture, and appear as coarse, dull white spots through 
the cell body, in films stained with this solution. The distinctive 
manner in which they react toward selective stains for mucin has 
recently been discovered by Harris, 1 who, in view of this fact, 
suggests that the term mucinoblast be applied to the mast cell. 

The author questions the identity of these coarsely granular 
basophilic blood cells with the well-known mast cell of the tissues, 
although most hematologists consider them identical. Both, 
it is true, contain granules which tinctorially and morpholog- 
ically are identical, but it is obviously impossible to determine 
cell identity by criteria such as these. The mast cell of the 
tissues differs from that of the blood in having a nucleus which is 
smaller in relation to the size of the cell body, more centrally 
situated, and richer in chromatin, hence being more deeply 
and more unevenly stained. The " explosive " nature of the 
tissue mast cell is also usually more striking, for while cells 
with this tendency are met with only occasionally in the blood, 
they seem to be the rule rather than the exception in the tis- 
sues, large numbers of them consisting of a nuclear structure sur- 

1 Phila. Med. Journ., 1900, vol. v., p. 757. 



CLASSIFICATION. 



171 



rounded by dense clusters of granules, which are frequently drawn 
out in long tentacular extensions. In view of these differences, it 
may be well to be more specific, by designating the mast cell 
found in the blood as the hemic mast cell. 

This term has been applied by Capps 1 to a form 
Mononuclear of leucocyte which he found in certain cases of 
Neutro- general paralysis of the insane, its appearance 
philes. in the blood having been noted after apoplectiform 
attacks, and preceding death. This cell is as 
large as, or larger than, the polynuclear neutrophile, contains a 
round or ovoid nucleus which is deeply stained by basic dyes, 
and has a protoplasm thickly sprinkled with fine neutrophile 
granules. Capps suggests that the ceil may be a form of leuco- 
cyte of slightly more mature development than the large lympho- 
cyte, one in which the development of the granules has preceded 
the nuclear changes. The close resemblance of these cells to 
the smaller forms of myelocytes, however, makes it reasonable 
to class them as such. 

Ehrlich has recently described 2 as a " small 
Neutrophilic neutrophilic pseudolymphocyte " a cell of the 
Pseudolym- same size as that of the small lymphocyte, and 
phocytes. characterized by a relatively large, round, intensely 
basic nucleus, surrounded by a narrow zone of 
protoplasm filled with neutrophile granules. This cell, it is 
maintained, is of a very rare occurrence, having been found in the 
blood only in a case of hemorrhagic small-pox, and in the exudate 
of a recent pleural effusion. Ehrlich differentiates it from a myelo- 
cyte by its small size, deeply staining nucleus, and scanty amount 
of protoplasm, but these points of distinction do not appear con- 
clusive, for many of the smaller, "dwarf" forms of myelocytes 
have similar characteristics. It does not appear unreasonable, 
therefore, to regard this cell as an exceedingly small form of 
myelocyte, in which the nucleus is relatively larger and richer in 
chromatin than is the rule in the larger, more typical varieties. 

These cells, first described by Turk 3 as u rei- 
" Reizungs- zungsformen " (or, literally , " stimulation forms "), 
formen." are said to occur in the same pathological condi- 
tions in which myelocytes are found, but as yet 
their exact significance is undetermined. The size of the cell is 
usually midway between that of the small and large lymphocyte, 
more often approximating the size of the former. The cell con- 

^-Amer. Journ. of Med. Sciences, 1896, vol. cxi., p. 650. 
2 Loc. cit. 

3 Cited by Ehrlich, loc. cit. 



172 



THE LEUCOCYTES. 



tains a round nucleus, deficient in chromatin, often eccentrically 
placed in the cell body, and reacting with moderate intensity to- 
ward the basic aniline dyes. The protoplasm is non-granular, 
and stains an intense brown with the triacid mixture. Ehrlich 
suggests that this cell may possibly represent an early stage of the 
erythroblast, but reasons for such an inference do not seem clear. 
The writer has seen such cells in the blood of the post-typhoid 
anemias of infancy, always in association with lymphocytosis. 

The chief points of distinction between the different forms of 
leucocytes, as recognized in specimens stained with Ehrlich's 
triacid mixture, are tabulated below. 



Form of Cell. 



Size. 



Nucleus. 



Protoplasm. 



Small lymphocyte. 



Large mononuclear 
leucocyte, or 
large lymphocyte. 

Transitional leuco- 
cyte. 



Polynuclear neutro- 
phils 



Eosinophile. 



Basophile. 



Myelocyte. 



Mast cell. 



Reizungsform. 



6 to 9 (i. 



io to 15 [I. 



10 to 15 fl. 



7.5 to 12 fl. 



7.5 to 12//. 



7.5 to 12//. 



IO to 20 fl. 



7 to 22 fl. 



6 to 15 fi, 



Single. 
Round. 

Relatively large. 
Dark blue or purple. 
Single. 

Round or ovoid. 
Relatively small. 
Very pale blue. 
Single. 

Indented, kidney- 
shaped, or cres- 
centic. 

Relatively small. 

Pale blue. 

Polymorphous or 
polynuclear. 

Relatively small. 

Moderately dark 
blue. 

Polymorphous or 
polynuclear. 

Relatively small. 

Pale blue. 

Polymorphous. 

Relatively small. 

Dull blue. 

Single. 

Round or ovoid. 
Relatively large or 

small. 
Very pale blue. 
Single. 

Round, ovoid or 
slightly lobulated. 
Relatively large. 
Very pale blue. 
Single. 
Round. 

Relatively small. 
Deep blue. 



Relatively small amount. 
Non-granular. 
Unstained, or faint pink. 

Relatively large amount. 
Non- granular. 
Unstained, or faint pink 

or grayish-blue. 
Relatively large amount. 
Non-granular. 
Unstained, or faint pink 

or grayish-blue. 



Relatively large amount. 

Contains fine lavender or 
purple neutrophile 
granules. 

Relatively large amount. 

Contains coarse red or 
copper-colored eosino- 
phile granules. 

Relatively large amount. 

Contains fine basophile 
granules, unstained. 

Relatively large or small 
amount. 

Contains fine lavender 
or purple neutrophile 
granules. 

Relatively small amount. 

Contains coarse baso- 
phile granules, un- 
stained. 

Relatively large amount. 
Non-granular. 
Intense brown. 



CLASSIFICATION. 



173 



Two different views are current at the present 
Origin and time regarding the origin and development of the 
Develop- leucocytes, the first being that of Ehrlich 1 and 
ment. his followers, and the second that maintained by 
the Russian school, led by Uskow 2 and his pupils. 
According to Ehrlich' s teachings, the small lymphocyte and 
its mother-cell, the large lymphocyte, are developed in the lym- 
phatic tissues in the various parts of the body, wherever such 
structures exist. The large mononuclear leucocytes and transi- 
tional forms are considered probably of myelogenous origin. 
The polynuclear neutrophiles are thought to develop exclusively 
in the bone marrow, the great majority being evolved from the 
neutrophilic myelocytes of this tissue, while a very limited num- 
ber perhaps arise from the non-granular large mononuclear cells. 
The eosinophiles develop from the eosinophilic myelocytes in the 
bone marrow, while the basophilic leucocytes similarly have their 
origin in basophilic marrow antecedents. Thus, it is maintained 
that all varieties of leucocytes may be classed in two distinct 
groups which have separate origins, functions, and relations. 
The first group consists of the lymphocytes, large and small, 
which are produced solely by the lymphatic tissues ; and the 
second group includes the mononuclear leucocytes and transi- 
tional forms, the polynuclear neutrophiles, the eosinophiles, and 
the basophiles, all of which cells are produced exclusively by 
the marrow. Cellular reproduction, except in rare instances, 
does not take place in the circulating blood stream. 

The scheme devised by the Russian school contends for the 
continuous evolution of the leucocyte from its earliest to its most 
mature stages. Accordingly, all varieties of the leucocyte, except 
the basophilic cells of which no account apparently is taken, are 
but different developmental stages of one and the same cell. 
The youngest form of leucocyte, the small lymphocyte, originates 
in the lymph glands, the lymphocytic bone marrow, and the 
spleen, from which sources of origin it reaches the circulation. 
The small lymphocyte enlarges until it becomes identical 
in appearance with the cell recognized as the large lymphocyte, 
its nucleus at this period of its growth having become somewhat 
less intensely basic, although the basic affinity shown by the cell- 
protoplasm is unaltered. The large lymphocyte in turn under- 
goes a simple increase in size, its nucleus meanwhile becoming 
progressively paler and its protoplasm more feebly basic, until 

1 Loc. cit. 

2 "The Blood as a Tissue," 1890. (Russian. ) Also series of articles by Uskow' s 
pupils in Archiv. d. Sc. Biol., St. Petersburg, 1893-97. 



174 



THE LEUCOCYTES. 



it develops into the large mononuclear form. The nucleus of 
the latter now becomes indented and moulded into a roughly 
crescentic figure, its nuclear and protoplasmic characteristics re- 
maining unchanged, and the so-called transitional form thus origi- 
nates — a type of cell which is regarded as the immediate ante- 
cedent of the polynuclear neutrophile. During the next stage of 
development the size of the transitional cell decreases, and the 
whole cell becomes ameboid ; the nucleus becomes denser, more 
basic, and polymorphous or polynuclear ; while the protoplasm 
loses the last trace of its basic tendency, and becomes sprinkled 
with fine neutrophile granules, until finally the mature form of 
leucocyte, the polynuclear neutrophile, is fully developed. The 
final, or " over- ripe " stage of the leucocyte is represented by the 
eosinophile, which is thought to be derived from the polynuclear 
form, by a transformation of the latter' s neutrophile into eosino- 
phile granules. It is maintained that these transitions from one 
form of cell to the other occur partly in the circulating blood, 
and partly in the blood-forming tissues, most largely in the 
latter. 

It is beyond the province of this book to discuss the merits 
and demerits of these two opposing views, but it may be remarked 
that Uskow's theory, which up to the advent of Ehrlich's observa- 
tions, commanded general attention among hematologists, is now 
being rapidly supplanted by the latter. The investigations of 
Ehrlich in this direction constitute the only dependable means 
by which many of the pathological changes in the leucocytes 
may be explained, and his views may be accepted on the whole 
as accurate. 

In all purulent conditions, as well as in many 
Iodine other diseases, the protoplasm of the leucocytes 
Reaction. shows a more or less pronounced affinity for io- 
dine, as demonstrated by staining with a weak so- 
lution of this metal. For this purpose Goldberger and Weiss 1 
have recommended the following reagent : 

Iodine i 

Potassium iodide 3 

Distilled water , . 100 

Mix and add sufficient gum arabic to make a syrupy 
mixture. 

With a camel's hair brush a layer of this solution is painted 
over the surface of the dried, unfixed blood-film, upon which it 
is allowed to act for from one to five minutes. The excess is 

1 Wien. klin. Woch., 1897, vol. x., p. 601. 



CLASSIFICATION. 



175 



then removed, by blotting with a bit of filter-paper, and the speci- 
men is mounted in cedar-oil. 

In films thus treated the iodine reaction is recognized by a 
slight or intense, diffuse brown coloring of the entire protoplasm, 
or by the presence throughout the protoplasm of numerous in- 
tensely stained, reddish-brown granules, the latter change being 
the more common. In normal blood the protoplasm of the leu- 
cocytes is stained a pale yellow, and the nuclei remain almost 
colorless. 

The above reaction, which is constant in all purulent conditions, 
persists as long as the suppurative focus exists, but its intensity 
appears to bear no parallelism to the extent of the pus col- 
lection. It is absent in pure tuberculous abscesses. It is also 
present with great constancy in puerperal sepsis and in other 
forms of septicemia, and frequently in pneumonia, in pulmonary 
tuberculosis, in malignant disease, and occasionally in marked ca- 
chexias. Hofbauer 1 found iodinophile granules in the leucocytes 
in all cases of pernicious anemia, their number being greatest in 
the gravest cases ; they were also present in severe forms of sec- 
ondary anemia, and in leukemia, but were absent in chlorosis, 
and in pseudoleukemia. This author also observed numerous 
iodine-stained extracellular masses in a case of purpura hemor- 
rhagica. Kaminer 2 believes that the reaction depends upon three 
factors for its production — pyrexia, leucocytosis, and toxemia, 
and that it is caused by the action of some unknown chemotactic 
substance. He has also apparently shown that the brownish-red 
color of the reaction does not depend upon the presence of gly- 
cogen in the leucocytes, as most observers have claimed, since in 
four cases of diabetes mellitus the test was negative. 

The practical value of this test is limited, in view of the many 
different circumstances under which it may prove positive. Its 
constancy in purulent conditions, however slight in extent the 
focus of pus, may be of some use in diagnosing a deep-seated 
abscess, if other causes which also may give rise to the reaction 
can be ruled out. Its absence in pure tuberculous abscess and 
its presence in all other forms of abscess may aid in distinguish- 
ing between the two, and of ascertaining whether a mixed infec- 
tion exists. Although the writer has followed out rather at length 
the suggestion made by Holbauer, that the intensity of the reac- 
tion serves as an index to the severity of an anemia, the results 
from this study have not shown the reliability of such a presumption. 

1 Centralbl. f. inn. Med., 1900, vol. xxi., p. 153. 

2 Deut. med. Woch., 1899, vol. xxv., p. 235. See also Berl. klin. Woch., 1899, 
vol. xxxvi. , p. 119. 



i;6 



THE LEUCOCYTES. 



Neusser, 1 in 1894, described certain basic 
Perinuclear granules about the nuclei of the leucocytes, 
Basophilia, which he regarded as pathognomonic of the uric 
acid diathesis, asserting that this so-called " peri- 
nuclear basophilia" could be demonstrated constantly in gout, 
lithiasis, rheumatism, leukemia, and a number of other diseases. 
These statements were soon corroborated by Kolisch, 2 and for a 
time enjoyed more or less general credence. The later researches 
of Futcher 3 and of Simon, 4 however, have entirely disproved the 
claims of Neusser and his school, for these investigators, working 
independently, have proved that perinuclear basophilia is not 
only quite uncharacteristic of the uric acid diathesis, but that it 
can be constantly demonstrated in every sort of blood, whether 
from healthy or from diseased persons. It is now clear that 
Neusser' s granules are simply artefacts, due to some slip in the 
technique of staining. Ehrlich 5 believes that their presence is 
but rarely noted, if perfectly pure crystalline dyes are used in 
preparing the stain. 

III. LEUCOCYTOSIS. 

Leucocytosis may be described as an increase above the normal 
standard in the number of leucocytes in the peripheral blood, this 
change either (a) involving both an absolute and relative increase 
in the polynuclear neutrophil cells with a consequent relative dimi- 
nution in the proportion of mononuclear non-granular forms, or (J?) 
affecting all varieties of leucocytes alike. 

A leucocytosis of the first kind, also termed a polynuclear neu- 
trophile leucocytosis, is by far the more common of the two types ; 
it may be symptomatic either of pathological or of physiological 
conditions, being found almost invariably in the former, and fre- 
quently in the latter. A leucocytosis of the second kind, or a 
general increase unattended by any disturbance in the normal 
relative proportions of the different forms of cells, is compara- 
tively rare ; it is more frequently dependent for its production 
upon physiological than upon pathological factors, but it may 
occur under either of these circumstances. 

From these facts it is obvious that simply an increase in the 
total number of leucocytes, without regard to the differential 
changes involved, does not of necessity constitute a leucocytosis. 

1 Wien. klin. Woch., 1894, vol. vii., p. 71. 

2 Ibid., 1895, vol. viii., p. 797. 

3 Bull, of the Johns Hopkins Hosp., 1897, vol. viii., p. 85. 

4 Am. Journ. of Med. Sciences, 1899, vol. cxvii., p. 139. 

5 Loc. cit. 



PLATE III. 



Leucocytosis. 
( Triacid Stain.) 



The blood field from a case of croupous pneumonia. The leucocytes are all of the polynuclear 
neutrophile type. The erythrocytes show no deformity, and stain a normal orange 
color. 

Contrast this illustration with leukemia, Plates IV and V. 



(E. F. Faber, /<?£.) 



PHYSIOLOGICAL LEUCOCYTOSIS. 



177 



Nor is it possible to recognize the condition with certainty by any 
such criterion as a deviation from the ratio of red to white cells 
maintained in health. To state that a patient's blood contains, 
say, 50,000 leucocytes to the cubic millimeter suggests both leu- 
cocytosis and leukemia, but to add to such a statement the fact 
that of these 50,000 leucocytes 90 per cent, are of the polynuclear 
neutrophile variety at once stamps the condition as a genuine leu- 
cocytosis. In order, therefore, to distinguish leucocytosis with 
absolute certainty the character of the leucocytes involved in the 
increase must be determined by a differential count of the 
stained specimen of blood. (See Plate III.) 

Leucocytosis may be of a more or less transient character, or 
may persist for a long period, its duration being dependent upon 
the nature of the underlying cause. In acute diseases it is usually 
a temporary condition, but in long-continued affections it is pro- 
longed in relation to the chronicity of the lesion by which the 
increase is excited. 

For clinical purposes all forms of leucocytosis may be classed 
under two main groups, physiological and pathological, these be- 
ing further divided as follows : 

Physiological Leucocytosis. 

1 . Leucocytosis of the new-born. 

2. Digestion leucocytosis. 

3. Leucocytosis of pregnancy and parturition. 

4. Leucocytosis due to thermal and mechanical influences. 

5. Terminal leucocytosis. 

Pathological Leucocytosis. 

1. Inflammatory and infectious leucocytosis. 

2. Leucocytosis of malignant disease. 

3. Post-hemorrhagic leucocytosis. 

4. Toxic leucocytosis. 

5. Experimental leucocytosis. 

PHYSIOLOGICAL LEUCOCYTOSIS. 

The leucocytoses associated with a number of 
Character, purely physiological conditions are generally of 
brief duration, and as a rule involve a moderate 
increase in the white corpuscles, the gain in many instances being 
trifling and never excessive. As noted in a preceding paragraph, 
12 



1/8 



THE LEUCOCYTES. 



the increase sometimes affects all forms of leucocytes equally, so 
that, although the total number of cells is higher than the normal 
standard, the relative percentages of the different varieties remain 
in the ratio observed in normal blood. In other instances the 
gain is due to an absolute and relative increase in the polynuclear 
neutrophile leucocytes, with a consequent decrease in the per- 
centage of non-granular, mononuclear forms. 

The increase of leucocytes under such condi- 
Causal tions is to be regarded usually as a physical 
Factors. phenomenon depending upon temporary concen- 
tration of the blood, or upon an unequal distri- 
bution of the cells in favor of the peripheral vessels. Evidence 
is wholly lacking to show that it is caused by an actual over-pro- 
duction of leucocytes by the blood-forming organs, thus produc- 
ing a general increase through all parts of the body. It is, 
therefore, reasonable to believe that the high leucocyte counts 
may be accounted for by such factors as decrease in the total 
volume of blood plasma, and the transference of cells from the 
vessels of the deeper tissues to those of the superficial parts of 
the body. 

I . Leucocytosis of the New-born. The blood of the infant at 
birth contains two or three times the number of leucocytes found 
in the normal adult, the count usually ranging from 15,000 to 
20,000 or higher during the first forty-eight hours of life. After 
this time the number of cells gradually decreases until, by the 
end of the first or second week, it has fallen to an average of 
from 10,000 to 1 5,000, which figures may be considered normal 
for children under one year of age. Gundobin 1 has determined, 
by a series of differential counts, that the increase is due chiefly 
to an excessive gain in the polynuclear neutrophiles, the propor- 
tion of these cells during the first ten days after birth averaging 
from 60 to 70 per cent, of all forms of leucocytes. The extent 
of this increase becomes apparent when one recalls the fact that 
in the infant the relative proportion of these cells to the other 
varieties is usually not more than 40 per cent. By the tenth day 
this polynuclear increase usually subsides, and the percentage of 
mononuclear forms rises to the figure normal at this period of 
life. (See Section VI.) In prematurely-born infants a similar in- 
crease in the number of leucocytes is present, but the mononu- 
clear forms rise to their normal percentage more rapidly than in 
the full-term baby ; thus, in the case of an eight-months' child, 
examined by Whitney and Wentworth, 2 the large and small lym- 

a Jahrb. f. Kinderheilk. , 1893, vol. xxxv., p. 187. 

2 Cited by Rotch : "Paediatrics," etc., Phila., 1896, p. 348. 



PHYSIOLOGICAL LEUCOCYTOSIS. 



179 



phocytes, which averaged together but 26 per cent, at birth, rose 
to 80 per cent, by the fourth day, remaining at practically this 
figure through subsequent counts. 

The leucocytosis of the new-born is probably attributable 
partly to concentration of the blood by the drain on the body- 
fluids incident to the early days of life, and partly to the influence 
of digestion leucocytosis which is especially active at this period. 

2. Digestion Leucocytosis. Within an hour after taking food 
an appreciable increase in the number of leucocytes may be ob- 
served in the great majority of healthy individuals, the count 
reaching its maximum within from two to four hours after the 
meal, and then gradually declining. Rieder 1 estimates the aver- 
age increase at about 33 per cent, in excess of the normal figure. 
Meals rich in albuminoids are followed by a more marked increase 
than those consisting chiefly of vegetable articles of diet. In in- 
dividuals whose process of digestion is slow from any cause the 
appearance of the leucocytosis is also delayed. The following two 
instances, taken from von Limbeck, 2 illustrate the development of 
the leucocytosis in the normal adult : 



Time. 



M.3 

M. 
M. 
M. 
M. 
M. 



Count of Leucocytes. 



7,600 
6,000 
8,500 
12,000 
14,000 
IO.OOO 



Time. 



Count of Leucocytes. 



11.30 A. 
12.30 P. 



M.3 
M. 

1.30 P. M. 
2.30 P. M. 



3-30 P- 
6.00 P. 



5,8oo 
10,600 
10,600 
9,600 
6,800 
6,600 



The gain is due usually to a predominance of polynuclear neu- 
trophile forms, with a consequent relative diminution in large and 
small lymphocytes ; but in some instances the differential count 
remains normal, all forms of cells sharing equally in the increase. 

Digestion leucocytosis is not invariably present even in those 
who apparently enjoy perfect health, its absence in such instances 
remaining entirely unexplained. It is also absent occasionally in 
chronic constipation, frequently in chronic gastric catarrh, and 
anemia, and is found in only a small proportion of cases of gastric 
carcinoma. Other lesions of the gastrointestinal tract, and dis- 
eases characterized by high-grade anemia and by marked de- 
bility may greatly delay or even entirely prevent the increase. 
Rieder 4 is authority for the statement that digestion leucocytosis 

1 " Beitrage zur Kenntniss der Leukocytose," etc., Leipzig, 1892. 
2 Loc. cit. 

3 Meal of nitrogenous and farinaceous food. 
4 Loc. cit. 



i8o 



THE LEUCOCYTES. 



does not occur during pregnancy, and Bohland 1 finds that it fails 
to develop during the administration of tannic acid. 

In children, especially in young breast-fed infants, the increase 
is very decided ; in the new-born counts of from 30,000 to 35,000 
may follow the first few feedings. (See Section VI.) Theleucocy- 
tosis is also marked after fasting, and in diabetics. 

3 . Lencocytosis of Pregnancy and Parturition. In the maj ority of 
primiparas a moderate leucocytosis, not usually involving an in- 
crease in excess of double the normal count, is observed during 
the later months of pregnancy. The increase is less constant 
and much less marked in multiparse, occurring in a smaller per- 
centage of the latter, and amounting to a cellular gain of about 
one-sixth the original count on the average. The maximum 
number of cells is usually found immediately before and after de- 
livery, at which time the number of leucocytes commonly rises 
to about 15,000 per cubic millimeter. During convalescence 
the leucocytosis gradually declines, and disappears before the 
end of the first week after delivery, in uncomplicated cases. 
As a general rule, in both primiparas and in multiparas, the de- 
gree of increase is more decided in young women than in those 
of middle age. It is also marked in the late rather than in the 
early stages of gestation and of labor. 

The careful blood studies by Hibbard and White 2 in 5 5 preg- 
nant women (33 primiparae and 22 multiparas) furnish the most 
reliable data concerning the leucocytosis of this condition. These 
authors found that leucocytosis occurred before delivery in 84 
per cent, of primiparae and in 75 per cent, of multiparas, the aver- 
age counts in 32 of the former being 15,021 (50 per cent, above 
normal) and in 20 of the latter 1 1,700 (17 per cent, above nor- 
mal). In uncomplicated pregnancies the average count just be- 
fore delivery was 16,100 for primiparae and 1 1,800 for multiparas. 
In normal labor the number of leucocytes fell rapidly after deliv- 
ery, gradually reached the normal standard by the fourth or fifth 
day, and then again slowly rose until the seventh day, when a 
decline to normal was again observed. 

Differential counts in 19 cases of the above series showed that 
the leucocytosis was of the polynuclear neutrophile type, a 
marked relative and absolute increase in these cells being con- 
stantly present ; as a rule their percentage was from 85 to 95 of 
all forms of leucocytes, usually being higher, the higher the leu- 
cocytosis. These results are unlike those obtained by Rieder 3 

^entralbl. f. inn. Med., 1899, vol. xx., p. 361. 
2 Journ. of Exper. Med., 1898, vol. iii., p. 639. 
3 Loc. cit. 



PHYSIOLOGICAL LEUCOCYTOSIS. 



181 



and by Bjorkman, 1 the former having stated that the various 
forms of cells remain practically normal, while the latter attrib- 
utes the increase to a predominance of mononuclear elements. 

Lactation, of itself, has no appreciable effect upon the leuco- 
cytes, so that a leucocytosis occurring in a nursing woman should 
be attributed to inflammatory condition of the breast or nipple — 
even a mild mastitis or a slight irritation of the nipple being cap- 
able of causing a prompt leucocytosis. 

The number of leucocytes is somewhat in excess of normal 
for a few days preceding and during menstruation in the majority 
of healthy women, according to the investigations of Sfameni, 2 
but the increase scarcely ever reaches a degree which may be 
regarded as a leucocytosis. 

4. Leucocytosis Due to Tliermal and Mechanical Influences. A 
transient increase in the number of leucocytes of the peripheral 
blood, not involving a disturbance of the normal ratio between the 
different forms of cells, is produced by active local or general 
muscular exercise ; 3 by brief exposure to atmospheric cold ; 3 by 
cold baths, either local or general ; 4 and by the application of 
electricity 3 and of massage. b The number of leucocytes is also 
increased by the effect of prolonged dry or moist heat. 6 

The increase under these circumstances is generally attributed 
to blood concentration due to the influence of increased vaso- 
motor tension, whereby the liquid elements of the blood are tem- 
porarily decreased, and, in addition, many of the cells lodged in 
the deeper tissues of the body are swept into the peripheral cir- 
culation. As a rule, all varieties of leucocytes share equally in 
the process, no single form being unduly increased at the ex- 
pense of the others. 

5. Terminal Leucocytosis. Terminal or pre-agonal leucocyto- 
sis is the term applied to an increase in the number of leucocytes 
of the peripheral circulation frequently observed just before death. 
It occurs during the terminal stages of a number of different 
diseases, and is especially marked in those conditions in which 
death comes slowly, being ushered in by a more or less mori- 
bund state of the patient lasting for a considerable length of time. 
The increase is usually moderate, and the counts do not often 
exceed 20,000 or 30,000 per cubic millimeter, except in those 

1 Am. Medico-Surg. Bull., 1894, vol. vii., pp. 17 and 79. 

2 Loc. cit. 

3 Oliver : loc. cit. 

4 Winternitz: Centralbl. f. klin. Med., 1893, vol. xiv., p. 1017. Thayer: Johns 
Hopkins Hosp. Bull., 1893, vol. iv., p. 37. 

5 Mitchell : Am. Journ. of Med. Sci., 1894, vol. cvii., p. 502. 

6 Friedlander : Congress f. inn. Med., Berlin, 1897. 



182 



THE LEUCOCYTES. 



cases in which decided circulatory embarrassment has existed for 
some time. Most commonly the blood-picture is one of ordinary 
polynuclear neutrophile leucocytosis, although occasionally the 
large and small lymphocytes show disproportionately high per- 
centages, and still more rarely all forms of cells may be increased 
equally. 

In pernicious anemia the increase may be so great as to simu- 
late lymphatic leukemia, according to Cabot, 1 who found the fol- 
ing blood changes on the day of death in this disease : ratio of 
white to red corpuscles, I to 15 ; differential count showed 91.7 
per cent, of lymphocytes, 7.7 per cent, of polynuclear neutro- 
phils, and 0.5 per cent, of eosinophiles. Four megaloblasts to 
one thousand leucocytes were also found. 

The following data were obtained by the writer in a case of 
pernicious anemia eighteen hours before death : hemoglobin, 
12 per cent; erythrocytes, 622,500 per cb. mm.; leucocytes, 
18,600 per cb. mm. The differential count of one thousand 
white corpuscles showed : lymphocytes, 46.0 per cent.; polynu- 
clear neutrophiles, 49.7 per cent.; eosinophiles, 2.3 per cent.; 
myelocytes, 1.6 per cent, and basophiles, 0.4 per cent. Meg- 
aloblasts outnumbered normoblasts three to one, twenty -four of 
the former being found in the count of one thousand leucocytes. 
The number of leucocytes in four previous counts having ranged 
from 1,000 to 2,400 per cubic millimeter, and the proportion of 
lymphocytes from 42 to 48 per cent., this case illustrates the oc- 
currence of a terminal leucocytosis without a notable change in 
the relative percentage of different forms peculiar to the case in 
question. 

The principal cause of this form of leucocytosis is thought to 
be peripheral stasis dependent upon failure of circulatory com- 
pensation, but in many instances there seems to be good reason 
to believe that terminal infections also act as the causal factors. 

PATHOLOGICAL LEUCOCYTOSIS. 

Increase in the number of leucocytes, involving 
Occurrence, chiefly the polynuclear neutrophile cells in the 
great majority of instances, is associated with a 
wide variety of pathological conditions, mainly inflammatory, in- 
fectious, and toxic in character, and in such conditions the under- 
lying cause of the phenomenon is radically different from that 
which determines the increase in physiological leucocytosis. 
Prominent examples of pathological lesions in which leucocytoses 



1 Loc. cit. 



PATHOLOGICAL LEUCOCYTOSIS. 



183 



of this character are observed are pneumonia, diphtheria, scarlet 
fever, erysipelas, rheumatic fever, variola, and various septic 
processes. Enteric fever, Malta fever, the malarial fevers, influ- 
enza, and measles are notable exceptions, for in these acute in- 
fections leucocytosis does not occur except as the result of some 
complication. 

The extent of the leucocytosis, inasmuch as it 
Degree of depends both upon the nature of the exciting cause 
Increase. and upon the individual's reactive powers, varies 
within wide limits in different cases. It is safe to 
state, however, that in the great majority of instances the number of 
leucocytes is rather below than above 20,000 to the cubic milli- 
meter, counts in excess of this figure being noted in only about 
one-fourth of the cases in which the leucocytes exceed the nor- 
mal limits of health. A count of 25,000 cells per cubic milli- 
meter may be regarded as a decided leucocytosis, while an in- 
crease of from 40,000 to 50,000 is of extremely rare occurrence. 
In an analysis of one hundred consecutive counts made by the 
writer in pathological conditions, in which the number of leuco- 
cytes reached or exceeded 10,000 per cubic millimeter, it was 
determined that the counts were below 20,000 in 65 per cent, of 
cases, and between 20,000 and 30,000 in 28 per cent.; in 4 per 
cent, the increase was between 30,000 and 40,000 ; in 2 per 
cent., between 40,000 and 50,000 ; and in only 1 per cent, did it 
exceed 50,000. Judging from these figures, which, it should be 
remembered, are applicable only to the average case, it appears 
to be the rule that in most leucocytoses the increase amounts to 
a trifle more than double the number normal in health. 

With rare exceptions, the increase affects chiefly 
Differential the polynuclear neutrophile cells, which com- 
Changes. monly constitute at least 85 per cent, of the dif- 
ferent forms of leucocytes. In many instances 
the percentage is much higher, as, for example, in a case of sup- 
purative meningitis, reported by Stengel, 1 in which a differential 
count showed 99.5 per cent, of this variety of cells. The excep- 
tional cases in which these disproportionately high percentages of 
polynuclear neutrophiles are sometimes wanting are encountered 
in the leucocytoses of malignant disease, after hemorrhage, in the 
moribund, and in children. The relative lymphocytosis which is 
occasionally observed under these circumstances is considered in 
connection with these conditions. Coincident with the increase 
in polynuclear forms, there is a marked decrease in the relative 
percentages of large and small lymphocytes, and of eosinophiles, 

1 Loc. cit. 



THE LEUCOCYTES. 



the latter variety of cells sometimes entirely disappearing from 
the blood. In cases in which the increase is marked, small num- 
bers of myelocytes usually may be observed, together with an 
occasional cell whose characteristics at once suggest a stage of 
development intermediate between that of the myelocyte and the 
typical polynuclear neutrophile. 

The exact manner in which pathological leu- 
Causal cocytosis arises is a question about which many 
Factors. conflicting views are held by different authorities, 

but the general trend of opinion at the present 
time attributes the increase chiefly to the influence of chemotaxis. 
According to the chemotactic theory of leucocytosis, the pres- 
ence in the blood of certain chemical substances, produced by in- 
fective principles, is capable of exerting both an attractive and a 
repellent influence upon the ameboid leucocytes. If the collec- 
tions of cells are attracted by such substances the phenomenon is 
known as positive chemotaxis, but if, on the other hand, they are 
repelled, the condition is termed negative chemotaxis. This mass- 
ing and repulsion of the leucocytes may be caused by various 
agents — by thermal and mechanical irritants, by bits of necrotic 
tissue which have gained entrance to the circulation, and espe- 
cially by the presence in the blood of bacteria, or of their meta- 
bolic products. In the light of our present knowledge, it appears 
that the different varieties of ameboid leucocytes respond to dif- 
ferent kinds of chemotactic influences, as an instance of which 
the behavior of the neutrophils and eosinophiles to this sort of 
stimulus may be cited. Certain substances, which for one of 
these groups of cells are either positively or negatively chemo- 
tactic, are, as a rule, indifferent to the other group, and some- 
times even antagonistic, for substances which serve to attract one 
group either fail to influence or in fact repel the other. Clin- 
ically, this theory seems to find corroboration, for there are but 
few exceptions to the general rule, that an increase in either 
variety of these cells is associated with a constant decrease in 
the other. Ehrlich 1 has also shown that the mast cells are 
wholly uninfluenced by those substances which exert a strong 
chemotactic influence upon the neutrophiles and eosinophiles. 

The intense cellular activity excited by the en- 
Functions. trance of bacteria into the organism indicates an 

attempt on the part of the leucocytes to destroy 
the invading principle, and to counteract its noxious influences. 
In this endeavor it is probable that in a restricted sense Metch- 
nikoff s hypothesis holds true, and that the immense numbers of 

1 Loc. cit. 



PATHOLOGICAL LEUCOCYTOSIS. 



185 



phagocytic leucocytes which crowd the blood stream mechan- 
ically engulf and destroy many of the invading micro-organisms. 
But of still greater significance is the facultv which the leuco- 
cytes possess of producing certain chemical substances (alexines) 
acting either as directly bactericidal, or as antitoxic agents. The 
researches of Buchner, 1 Lowy and Richter, 2 Goldscheider and 
Jacob, 3 and others tend to show that such substances either actu- 
ally destroy the infecting micro-organisms, or at least antidote 
and render innocuous their poisonous products. This joint proc- 
ess of phagocytosis and bactericidal action is most intensely de- 
veloped at the period of maximum leucocytosis, according to 
the statements of Gabritschewsky. 4 

In experimental leucocytosis, caused by the 
Hypolelcocy- injection of such irritants as bacteria and bacterial 
tosis and Hy- products, organic extracts, various albumins, and 
perleucocy- even by simple trauma, it has been found that the 
tosis. first effect of the irritant is to cause a rapid, tran- 
sitory diminution in the number of leucocytes in 
the peripheral blood, known as Jiypoleucocytosis, this decrease 
being succeeded in turn by an increase of these cells in excess of 
the normal standard, termed hyperleucocytosis. Frequently in 
simple traumatic leucocytoses after the disappearance of the stage 
of hyperleucocytosis, the duration of which is variable, Sher- 
rington 5 was able to distinguish a secondary stage of hypoleuco- 
cytosis, during which the leucocyte count again fell below the 
normal. 

Within certain limits, the extent of this preliminary decrease 
and of the subsequent increase varies directly in accordance 
with the intensity of the irritant. If the irritant is slight, the re- 
pellent influence is feeble, and the consequent cellular increase 
is inconspicuous — in fact, it is the opinion of many that in such 
instances there may be merely a local accumulation of leucocytes 
at the site of the injection, without any real increase in the whole 
mass of cells. If the effects of the irritant are severe, both the 
repellent and the attractive stages are promptly excited and 
markedly developed, and a general increase in the number of 
leucocytes through the whole circulatory system promptly re- 
sults. If, on the contrary, the effects of the irritant prove to be 
too intense, the organism suffers a depression so profound that 

1 Archiv. f. Hygeine, 1S90, vol. xvii., p. 112. 

2 Deut. med. VVoch., 1895, vol. xxix., p. 240. Virchow's Archiv., 1898, vol. 
cli., p. 220. 

3 Zeitschr. f. klin. Med., 1894, vol. xxv., p. 373. 
^Centralbl. f. Bakteriol., 1898, vol. xxiii., p. 365. 
5 Proc. of the Royal Soc, 1893, vol. lv., p. 161. 



THE LEUCOCYTES. 



reaction is stifled, and leucocytosis does not develop. It some- 
times happens that the attractive influences of the chemotactic 
principle predominate over its repellent action, in which case the 
stage of hyperleucocytosis may develop without the initial stage 
of hypoleucocytosis. Clinically, the preliminary decrease is prac- 
tically never observed, perhaps partly for the reason last given, 
but also in a large measure because the repellent action of the 
irritant has passed off by the time the disease has developed into 
a clinical picture. In artificially excited leucocytoses, however, 
its appearance is quite constant, for under such circumstances the 
irritant is introduced into the organism suddenly and in a rela- 
tively massive dose, producing a more or less decided repellent 
influence. 

The initial stage of decrease was termed the leucopenic phase 
by Lowit, 1 who attributed the change to an actual destruction of 
the leucocytes, or a leucocytolysis. The subsequent increase he 
spoke of as the leucocytic phase, maintaining that for the produc- 
tion of the latter the preliminary development of the former was 
in some unexplained manner essential. The work of Goldschei- 
der and Jacob 2 definitely proved the error of Lowit's leucocyto- 
lytic hypothesis, and demonstrated the fact that the leucopenia 
was dependent purely upon an altered distribution of the cells 
in favor of the vessels of the deeper circulation. Extensive 
investigations carried on by these authors showed that at 
the time a decided diminution occurred in the number of 
leucocytes of the peripheral blood, there was a simultane- 
ous increase of these cells in the capillaries of the lungs and 
other internal organs. Furthermore, it was also shown that in 
some instances a marked leucocytosis may occur without the ini- 
tial decrease, this being the case after the injection of such sub- 
stances as the glycerin extract of spleen. From these experi- 
ments it seems reasonable to attribute the initial stage of decrease 
to a repellent action of the irritant, and to infer that the stage of 
hyperleucocytosis is due to an active stimulation of the hemo- 
genic organs which results certainly in an increased cellular 
output from, and probably in an increased cellular proliferation 
in, this situation. Muir's recent investigations 3 tend to strengthen 
this belief, and to throw additional light on the phenomenon of 
pathological leucocytosis. This author found that in experimen- 
tal leucocytosis in animals, produced by the injection of patho- 
genic bacteria, changes occurred in the bone marrow, consisting 

K'Studien z. Physiol, u. Pathol, d. Blutes," Jena, 1892. 
2 Loc. cit. 

3 British Med. Journ., 1898, vol. ii., p. 604. 



PATHOLOGICAL LEUKOCYTOSIS. 



of absorption of the marrow fat, together with a corresponding 
hyperplasia of the cells from which he believes the leucocytes 
originate, many of these cells undergoing rapid multiplication by 
mitosis. In inflammatory leucocytosis, Muir found the following 
suggestive changes : first, a local increase in the polynuclear neu- 
trophile cells ; second, an increase of the same variety of cells in 
the circulating blood ; and third, a marked increase in the marrow 
of their direct antecedents. According to Ehrlich's latest views, 1 
leucocytosis involving mainly an increase of the polynuclear 
neutrophiles (''polynuclear neutrophile leucocytosis") is the ex- 
pression of an independent chemotactic reaction on the part of 
these cells, caused by the remote influence of dissolved substances 
upon the bone marrow, whereby this tissue throws into the blood- 
current excessive numbers of these elements. 

Schultz 2 and others, on the contrary, attribute leucocytosis en- 
tirely to changes in the distribution of the cells, maintaining that 
increase in the number of leucocytes in the peripheral vessels 
goes hand in hand with a decrease in their number in the vessels 
of the internal organs, and vice versa. This view, however, has 
been shown to be untenable. 

In summing up the various experimental and clinical data bear- 
ing upon the nature of the leucocytoses associated with patho- 
logical conditions, the evidence tends to confirm the view that the 
process is, in all instances, save perhaps those of trivial local in- 
fections, a general one throughout the entire circulatory system, 
and that it is symptomatic of an excessive output and rapid de- 
velopment of leucocytes by the bone marrow, due to the influence 
of chemotactic principles. It must be remembered that this view 
is in part based upon hypotheses, but it nevertheless represents 
the belief current at the present time. 

I. Inflammatory and Infectious Leucocytosis. In this class are 
included the leucocytoses occurring during the course of a num- 
ber of diseases of inflammatory and infectious character, in which 
the increase may be attributed either to simple inflammation, or to 
bacterial infection, or to both. The presence of such a leucocy- 
tosis is to be regarded as symptomatic of an attempt on the part 
of the organism to overcome the noxious invading principle, what- 
ever its nature may be, through the protective action of the white 
corpuscles. Bearing in mind this construction of the phenom- 
enon, it is possible in many instances to derive valuable clinical 
information from the presence or absence of a cellular in- 
crease. 

1 Loc. cit. 

2 Tagebl. der Naturforschervers in Heidelberg, 1SS9, p. 405. 



i88 



THE LEUCOCYTES. 



The view expressed by von Limbeck, 1 that the height of the 
leucocytosis is dependent upon the extent of the inflammatory ex- 
udate, is not tenable, for processes characterized by insignificant 
exudates are capable of causing as great an increase as those in 
which this outpouring is extensive. As a rule, leucocytoses as- 
sociated with purulent exudates are much more marked than 
those due to serous effusions. The essential factor in determining 
the degree of the increase is not the extent of the exudate, nor, 
in fact, its character, but rather the systemic reaction to which it 
gives rise. 

The degree of leucocytosis may be considered a general index 
to the intensity of the infection, and to the strength of the indi- 
vidual's resisting powers in reacting against it. It follows, 
therefore, that intense infections occurring in individuals whose 
resisting powers are strong produce a decided increase ; but 
the presence of an infection of like intensity in one whose re- 
sisting powers are greatly crippled fails to cause leucocytosis, 
for in such an instance the organism is so overpowered by the 
effects of the morbid process that it is incapable of reacting. 
The increase is either absent or slight when a trifling infection 
is associated with vigorous resisting powers, and moderate when 
a moderately intense infection is linked to fairly well-developed 
resisting powers. 

The clinical inferences to be drawn from these facts are of 
value chiefly as corroborative of other well-known physical 
signs, but are obviously untrustworthy when considered apart 
from the latter. A marked leucocytosis indicates simply an in- 
tense infection in a person whose resisting powers are normally 
developed and actively exerted against the disease, but it is of 
no prognostic value in itself, for it conveys no idea of the final 
outcome of the conflict between the disease and the organism. 
Absence of leucocytosis, or a slight increase may be either of 
very favorable or of very grave significance, inasmuch as these 
signs occur both in trivial and in overwhelming infections. If 
the absence is associated with clinical manifestations which point 
to a severe infection, the sign may be depended upon as being 
of grave prognosis. 

The clinical significance of the leucocytoses associated with 
various inflammatory and infectious processes will be discussed 
in Section VII. A more or less decided increase in the num- 
ber of leucocytes occurs with great constancy in the following 
groups of diseases of this nature : 



J Loc. cit. 



PATHOLOGICAL LEUCOCYTOSIS. 



I. General Infectious Diseases. 

Actinomycosis. 
Asiatic cholera. 
Bubonic plague. 
Cerebro-spinal meningitis. 
Diphtheria. 
Dysentery. 
Erysipelas. 
Glanders. 

Malignant endocarditis. 
Multiple neuritis. 
Osteomyelitis. 
Pertussis. 

II. Simple and Infective Lc 

Acute yellow atrophy of 
liver. 

Appendicitis, catarrhal. 
Arthritis, serous. 
Bronchitis, acute. 
Cholangitis. 
Cholecystitis. 
Cystitis. 

Conjunctivitis, acute. 
Dermatitis. 
Eczema. 
Endocarditis. 
Endometritis. 
Enteritis. 
Epididymitis. 
Gangrene : 

Appendicular. 

Cancrum oris. 

Hepatic. 

Pancreatic. 

Pulmonary. 
Gastritis, acute. 
Gastro-enteritis, acute. 
Herpes zoster. 
Infected wounds. 
Mastitis. 
Meningitis. 
Nephritis, acute. 
Orchitis. 
Otitis media. 
Ovaritis. 
Pancreatitis. 



Pneumonia. 
Pyemia. 

Relapsing fever. 

Rheumatic fever. 

Scarlet fever. 

Septicemia. 

Syphilis (secondary). 

Trichiniasis. 

Vaccinia. 

Varicella. 

Variola. 

Yellow fever. 

Inflammations, 

Pellagra. 

Pemphigus. 

Pericarditis. 

Peritonitis. 

Prurigo. 

Purulent lesions : 

Appendicular abscess. 
Cerebral abscess. 
Hepatic abscess. 
Ischio-rectal abscess. 
Ovarian abscess. 
Pancreatic abscess. 
Pelvic abscess. 
Perinephritic abscess. 
Prostatic abscess. 
Pulmonary abscess. 
Retropharyngeal abscess. 
Splenic abscess. 
Superficial abscess. 
Arthritis, suppurative. 
Carbuncle. 
Empyema. 
Felon. 
Furuncle. 
Gonorrhea. 

Otitis media, suppurative. 
Phlebitis. 
Pyelonephritis. 
Pyonephrosis. 
Pyosalpinx. 
Quinsy. 
Splenitis. 



190 



THE LEUCOCYTES. 



2. Leucocytosis of Malignant Disease. A moderate leucocytosis 
is commonly, but by no means constantly, associated with the vari- 
ous forms of carcinomata and sarcomata, but the cases in which no 
increase is observed are even more numerous than those in which 
it occurs. It is more common and the increase is usually re- 
garded as more marked in sarcoma than in carcinoma, but in 
neither condition are excessively high leucocytoses met with fre- 
quently. In the writer's experience, the increase, when it does 
occur, is generally moderate in most forms of malignant disease, 
counts of less than 20,000 leucocytes per cubic millimeter being 
the general rule. Cases in which the number of cells exceeds 
this figure are comparatively rare, but are distinctly more com- 
mon in sarcoma than in carcinoma ; it is especially in rapidly 
growing neoplasms of the lung, liver, and kidney that the cells 
rise to 30,000 or 40,000, or even 50,000 or more. In a series 
of 68 consecutive cases of malignant disease in the German and 
Jefferson hospitals less than one-half were accompanied by a 
leucocyte count of 10,000 or more, this figure being reached or 
exceeded in approximately 45 per cent, of cases of carcinoma, 
while in sarcoma such an increase was noted in almost 65 per 
cent. Five per cent, of all cases showed a high leucocytosis, 
that is, counts ranging between 30,000 and 50,000. (For 
further data concerning the leucocytosis of these conditions, see 
" Malignant Disease," Section VII.) 

The behavior of the leucocytes in malignant disease appears 
less contradictory when we inquire into the actual influence which 
these growths exert in provoking leucocytosis. It is the cur- 
rent belief that malignant disease, per se, has little if any in- 
fluence of this sort, and that the increase, if any occurs, is attribu- 
table to local inflammatory complications and to secondary septic 
infections, rather than to the specific toxic effects of the neoplasm 
itself. In some instances it is reasonable to suppose that the 
profoundly cachectic state of the patient also is an important de- 
termining factor. Clinically, it is observed that tumors of rapid 
development, involving a large area of tissue and complicated by 
extensive metastases cause decided, often high, leucocytoses ; while 
localized tumors, of small size and of slow growth, give rise to 
trifling, if any, increase. Variations from this general rule are 
the result of differences in the resisting powers of different indi- 
viduals, for the effects of this factor in causing leucocytosis are 
potent in this, as in other pathological conditions. 

Qualitatively, the leucocytes usually show a marked absolute 
and relative increase in the polynuclear neutrophiles, with a con- 
sequent diminution of the mononuclear forms. But in some in- 



PATHOLOGICAL LEUCOCYTOSIS. 



IQI 



stances, both of carcinoma and of sarcoma, the polynuclear forms 
are relatively below the normal percentage, and the lymphocytes 
increased, so that the blood picture is not one of leucocytosis, but 
rather one of relative lymphocytosis ; such a change seems es- 
pecially prone to occur in sarcoma of the lymphatic system, in 
which it may be so marked that it suggests lymphatic leukemia. 
There are certain cases of malignant disease in which the propor- 
tion of polynuclear neutrophils rises, although the total number 
of leucocytes is not increased ; the polynuclear gain is less than 
is usually found with high leucocyte counts, but it is sufficiently 
decided to be regarded as of the same significance as a frank leu- 
cocytosis involving an increase in the total number of cells. 

The eosinophiles are variously affected in different cases ; some- 
times they are greatly diminished, if not, indeed, entirely absent, 
as in most leucocytoses ; sometimes they are normal ; and some- 
times they are largely increased in number. The increase may 
be pronounced in sarcoma, this being due probably to involve- 
ment of the bone marrow by the growth, either directly, or by 
metastasis. 

Small numbers of myelocytes — .5 to 1 or 2 percent. — are ex- 
ceedingly common, being found with great constancy in cases 
with marked cachexia, especially in carcinoma. 

3. Post-hemorrhagic Leucocytosis. A leucocytosis of moderate 
grade commonly occurs as the result of hemorrhage due to trau- 
matism or to other causes. It has been found that in animals 
the stage of increase is preceded by a well-defined leucopenia, 
which develops immediately after the loss of blood. This 
initial leucopenia, however, has not yet been demonstrated 
in man, although it probably occurs. In an extensive traumatic 
hemorrhage the increase sometimes may be recognized in the 
peripheral blood within an hour after the accident, but usually it 
is not distinguishable until after the lapse of a longer period — 
from five to ten hours, as nearly as can be ascertained. In 
hemorrhage accompanying various pathological conditions, such, 
for example, as gastric ulcer, lung tuberculosis, or uterine dis- 
ease, the appearance of the leucocytosis is less prompt than in 
hemorrhage from trauma. The maximum increase is usually 
within moderate limits — approximately two or three times the 
normal standard. The injection of a salt solution decidedly aggra- 
vates the leucocytosis. As an illustration of the degree of leuco- 
cytosis which is commonly encountered, Rieder 1 noted in four 
cases (hematemesis from gastric ulcer, fatal hemophilia, and 
uterine hemorrhage) an average count of 22,625, the- maximum 

1 Loc. cit. 



192 



THE LEUCOCYTES. 



being 32,600, and the minimum, 15,100. Inasmuch as the 
height of the increase is thought to correspond to the strength 
of the organism's reaction in compensating the blood loss, it 
varies in different cases. In two individuals of equally strong 
regenerative powers a severe hemorrhage will produce a greater 
leucocytosis than a slight one. The duration of the increase also 
varies with the individual case, for it depends upon a similar fac- 
tor ; but in the majority of instances it does not last for more 
than three or four days, according to the investigations of Lyon. 1 
Leucocytoses excited by traumatic hemorrhage are prone to 
persist longer than those due to other causes, and the long-per- 
sisting increases which are sometimes associated with other path- 
ological lesions should be attributed to factors other than the 
actual loss of blood. In an instance of leucocytosis following 
venesection, Rieder 2 found that the increase persisted for twelve 
days. Head 3 found that in dogs the leucocytosis following ex- 
tensive hemorrhage lasted for at least seven days. 

In the great majority of instances the qualitative changes 
chiefly involve the polynuclear neutrophiles, which are greatly 
increased at the expense of the other forms of cells, but in an 
occasional instance it will be found that the mononuclear varieties 
are greatly in excess of their normal percentages, so that a lym- 
phocytosis is observed. Myelocytes may also be found in con- 
siderable numbers in many cases. 

4. Toxic Leucocytosis. Typical examples of toxic leucocytosis 
are found in poisoning by ptomaines, and by coal-gas, in both of 
which conditions the predominant influence of a toxic agency in 
producing the increase is self-evident. For the same reason the 
leucocytoses occurring as the result of ether narcosis, and in con*- 
vulsions and acute delirium, are included in this classification. In 
certain diseases, notably in the uric acid diathesis, in chole7nia, 
and in uremia, the presence in the blood of toxic principles is 
thought to be the underlying factor of the increase ; the same 
probably is true of a number of other diseases, which, for obvious 
reasons, have been classed with the infectious and inflammatory 
leucocytoses. 

The effect of gas poisoning is illustrated by the blood ex- 
amination of a patient recently admitted to the German Hospital, 
fatally poisoned by illuminating-gas. The leucocytes were in- 
creased to 32,000 per cubic millimeter, the gain being due to an 
excessive predominance of polynuclear neutrophiles, as determined 

1 Virchow's Archiv., 1881, vol. lxxxiv. , p. 207. 
2 Loc. cit. 

3 Journ. Am. Med. Assn., 1901, vol. xxxvii., p. 501. 



PATHOLOGICAL LEUCOCYTOSIS. 



193 



by the following differential count: small lymphocytes, 3.5 per 
cent.; large lymphocytes, 2.5 per cent.; polynuclear neutrophiles, 
92.0 per cent; eosinophiles, 0.5 per cent., and myelocytes, 1.5 
per cent. To what extent this increase depended upon the ac- 
tual toxic effects of the gas, and to what extent it was attribu- 
table to peripheral stasis (which was marked in this patient), is 
conjectural. 

The leucocytosis caused by ether narcosis has been exhaus- 
tively studied by von Lerber, 1 and by Chadbourne. 2 The inves- 
tigations of von Lerber included 10 1 cases, of which number leu- 
cocytosis was found in more than 95 per cent., the increase fre- 
quently amounting to two or three times the original count ; in 
the majority of instances, the maximum count was observed sev- 
eral hours after the anesthesia was produced. Chadbourne has 
carefully studied 21 cases, all of which showed a more or less 
decided leucocytosis, the minimum gain being 6 per cent., the 
maximum 73 per cent., and the average 37.3 per cent. He 
found that the leucocytosis developed more rapidly during the 
early part of the etherization, and that only exceptionally did it 
persist for more than twenty-four hours. Differential counts in 
five cases showed that all forms of cells were proportionately 
increased. This author attributes the increase to the irritating 
effects of the ether vapor upon the mucous membrane of the re- 
spiratory tract. Results similar to the above also have been ob- 
tained by Ewing, 3 and by Ames, 4 in the experimental etherization 
of animals. 

The leucocytosis associated with acute delirium and with con- 
vulsive seizures, due to a variety of causes, has been studied in 
detail by Capps, 5 and by Burrows. 6 Under such circumstances the 
increase is usually marked, and the height of the count in a gen- 
eral way is dependent upon the severity of the attack. The 
polynuclear neutrophiles are chiefly concerned in the increase, 
with a consequent decline in the proportion of mononuclear 
forms. The leucocytosis of this class of diseases is discussed 
more fully in Section VII. 

5 . Experimental Leucocytosis. Leucocytoses not differing es- 
sentially from those associated with various local and general 
infections, may be caused by the administration of many drugs, 

1 " Ueber die Einwirkung der Aethernarkose auf Blut u. Urin.," Inaug. Diss. Ber- 
lin, 1896. 

2 Phila. Med. Jour., 1899, vol. iii., p. 390. 
3 N. Y. Med. Journ., 1895, vol. lxi., p. 257. 
4 Journ. Am. Med. Assn., 1897, vol. xxix., p. 472. 
5 Am. Journ. of Med. Sciences, 1896, vol. cxl., p. 650. 
6 Ibid., 1899, v °l- cxvii., p. 503. 

13 



194 



THE LEUCOCYTES. 



chemicals, organic principles, bacteria, bacterial proteins, and by 
the application of intense irritants and revulsives to the surface of 
the body. No doubt, many of these leucocytoses should be 
classed either as inflammatory or as toxic, owing to the character 
of their exciting causes, but for the sake of convenience they may 
be grouped under this heading. 

Leucocytoses resulting from the administration, subcutaneously 
and by the mouth, of various drugs and other substances have 
been studied chiefly by the Continental investigators, to whom we 
are indebted for most of our present knowledge of this subject. 
The manner in which such agencies act in causing the increase is 
not at all clear in many instances, but, as a rule, the change is 
thought to be dependent upon chemotactic influences, as in in- 
flammatory and infectious leucocytoses, as well as upon concen- 
tration of the blood from vasomotor changes. 

Lowit 1 determined that a preliminary leucopenia succeeded by 
a more or less decided leucocytosis followed the subcutaneous in- 
jection of the following substances : hemialbumose, pepsin , nuclein, 
?iucleic acid, car are, leech extract, tuberculin, filtered yeast-cultures, 
pyocyanin, sodium urate, and uric acid. This change was not ob- 
served, however, after the injection of urea. 

Goldscheider and Jacob, 2 conducting a large number of experi- 
ments with various organic animal extracts, obtained results simi- 
lar to Lowit' s from the injection of the extracts of spleen, thymus, 
and bone marrow, but found negative results from the use of the 
extracts of thyroid, pancreas, and liver. 

Winternitz 3 studied the effects resulting from the subcutaneous 
injection of substances causing both transient inflammatory edema, 
and aseptic abscess formation at the site of the injection. In the 
former class, which includes neutral salts, and dilute acids and 
alkalies, an increase in the number of leucocytes, amounting to 
from 40 to 75 per cent, of the original count, was noted ; and it 
was furthermore found that even although a local necrosis was 
produced, as by the injection, for example, of a solution of silver 
nitrate, the increase still did not become excessive. In the second 
class of more active irritants which produced local abscesses — tur- 
pentine, oil of mustard, carbolic acid, croton oil, sapotoxin, digitoxin, 
silver nitrate, cupric sulphate, and salts of mercury and of antimony 
— the leucocytosis was much more decided, and of less transient 
duration. As a rule, in these experiments the height of the leucocy- 
tosis ran parallel to the intensity of the local irritation provoked. 

1 Loc. cit. 
2 Loc. cit. 

3 Archiv. f. exp. Pathol, u. Pharmak., 1895, vol. xxxv., p. 77. 



PATHOLOGICAL LEUCOCYTOSIS. 



195 



Pohl 1 noted a moderate leucocytosis following both the inges- 
tion and the injection of absinthe, acetic ether, extract of gentian, 
peppermint, piperine, the oils of anise and fennel, egg-albumin, 
and sodium albuminate. With the last two substances he deter- 
mined that the increase was greater when they were given by the 
mouth than when administered subcutaneously ; the gain usually 
ranged from about 5 to 50 per cent, of the normal count. This 
investigator also found that quinine, caffeine, calomel, sodium bicar- 
bonate 3 ethyl alcohol, and hydrochloric acid did not cause a leucocy- 
tosis, while bismuth subnitrate and oxide of iron produced irregular 
results. Many of the above experiments have been substantiated 
by the later work of von Limbeck. 2 

Wilkinson 3 observed leucocytosis, preceded by leucopenia, 
after the injection of potassium iodide, camphor, quinine, antipyrin, 
salicine, salicylic acid, nuclein, and pilocarpine ; by the repeated 
administration of the latter drug, it was found that the granules 
of the polynuclear neutrophiles disappeared, although no effect 
was produced upon the granules of the eosinophile cells. Von 
Jaksch 4 also studied the effects of the injection of pilocarpine, and 
of the administration by the mouth of nuclein, and found that by 
either procedure a temporary and sometimes very marked leu- 
cocytosis may be produced. The leucocytosis caused by the 
ingestion of salicylic acid, according to Schreiber and Zandy, 5 
gradually disappears after the drug has been given for a few 
days. 

The effects of the ingestion of the essential oils of peppermint, 
turpenti?ie, and cinnamon have been studied by Meyer, 6 while 
Hirt 7 has investigated the influences of the simple bitters and 
drugs such as the tincture of myrrh. Such drugs were found to 
cause a moderate, but easily recognized leucocytosis. Krausman, 8 
by the injection of spermin, and of protalbumose , and Besredka, 9 
by a similar use of carmine and of arsenic trisulphate, have ob- 
tained varying degrees of increase in the number of leucocytes. 
A marked increase is produced, according to Bohland 10 by the 
injection of morphine, Dover's powder, sodium salicylate, pilocar- 
pine, antipyrin, phenacetin, and antifebrin. 

1 Archiv. f. exp. Pathol, u. Pharmak., 1889, vol. xxv., p. 51. 
2 Loc. cit. 

3 British Med. Journ., 1896, vol. ii., p. 836. 
*Centralbl. f. klin. Med., 1892, vol. xiii., p. 81. 
5 Deut. Arch. f. klin. Med., 1899, vol. lxii., p. 242. 

6 Cited by von Limbeck, loc. cit. 

7 Ibid. 

8 These de St. Petersbourg, 1898. 

9 Annal. de l'Institut Pasteur, 1899, vol. xiii., p. 49. 
10 Centralbl. f. inn. Med., 1899, vol. xx., p. 361. 



196 



THE LEUCOCYTES. 



In addition to the substances already mentioned, the leucocy- 
tosis-producing effect of various purgative drugs ? of the transfusion 
of blood and of normal salt solution? of the subcutaneous use ot 
fibrin ferment? of hemoglobin? and of bacterial cidtures? extracts? 
and proteins 6 has also been demonstrated. 

Thymectomy in animals is followed by a well-marked leuco- 
cytosis, associated with an increase in the bactericidal properties 
of the blood. 

IV. LYMPHOCYTOSIS. 

An increase, whether relative or absolute, in the lymphocytes 
above the number normal in health is known as lymphocytosis. 
Relative lymphocytosis involves simply a gain in the percentage 
of lymphocytes without a coincident increase in the total leucocyte 
count. Absolute lymphocytosis, on the other hand, is character- 
ized by an increase above normal both in the percentage of lympho- 
cytes and in the total number of leucocytes. Barring lymphatic 
leukemia, in which the lymphocytes are both relatively and abso- 
lutely in excess, lymphocytosis is almost always a relative condi- 
tion, or at least it is not accompanied by a decided rise in the 
total leucocyte count. 

The increase in the proportion of lymphocytes is moderate in 
most instances, the greater number of differential counts showing 
percentages of these cells ranging from 50 to 70, in comparison 
with the maximum normal percentage, about 30. These figures, 
of course, refer to the blood of adults, for in children the increase 
is generally greater, owing to the higher proportion of lympho- 
cytes normally found at this period of life. A differential count 
which shows, for instance, 60 per cent, of lymphocytes means a 
decided lymphocytosis in the adult, but is entirely within the 
normal limits in the young infant. Either type of cells, large or 
small, may predominate, or the change may not involve any con- 
spicuous deviation from the normal ratio of one form to the other. 
Frequently it happens that the two varieties possess such similar 
characteristics that it is impossible to determine which prevails. 
Occasionally the lymphocytosis depends largely upon unusually 
large percentages of the so-called "transitional" forms. 

Lymphocytosis may be due either to changes in the distribu- 
tion of the cells through the circulatory system, or to their in- 

1 De Rienzi and Boeni : Gaz. degli Osp. e. d. Clin., 1898, vol. xix., p. 1570. 

2 Hand: N. Y. Med. Journ., 1900, vol. lxxi., p. 556. 

3 Birk : " Das Fibrin -Ferment im lebenden Organismus," Dorpat, 1880. 
4 Bojanus: "Exp. Beitrage z. Physiol, u. Pathol, d. Blutes," Dorpat, 1881. 

5 Hankin and Kanthack : " Proc. Cambridge Philosoph. Soc.," Jan., 1892. 

6 Buchner : Arch. f. Hygiene, 1890, vol. x. , p. 84. 



LYMPHOCYTOSIS. 



I 9 7 



creased production and output by the lymphatic tissues. Ehr- 
lich 1 attributes lymphocytosis to the local irritation of certain 
areas of lymphatic glands which produces an increased circulatory 
activity in these situations, in consequence of which large numbers 
of lymph elements are swept mechanically from the lymphatics, 
and enter the general circulation. He does not regard the change 
as an expression of an active chemotactic reaction, to which the 
lymphocytes are insensible. It also appears reasonable to pre- 
sume that the lymphocytosis which often accompanies leucopenia 
may be traced to still another factor, that of negative chemotaxis, 
which diminishes the number of polynuclear neutrophiles, and 
thus brings about a relative increase in the lymphatic elements, 
upon which the repellent action is not exerted. 

Lymphocytosis has been observed in a number of pathological 
conditions, but its presence may be considered physiological in 
but a single instance — in the blood of infants and young children, 
in whom such a change is entirely normal. This tendency to- 
ward a lymphocytic increase in infantile life, which becomes less 
notable as the child matures, is prone to become markedly exag- 
gerated in many of the forms of secondary anemia from which 
children suffer, especially the anemias secondary to syphilis, tuber- 
culosis, rachitis, gastro-enteritis, and scurvy ; less commonly, it 
has been observed in the acute infections. 

Lactation, conditions of cachexia, and great debility in the 
adult are in many instances accompanied by abnormally high per- 
centages of lymphocytes in the blood. It is a well-known fact 
that differential counts show a higher percentage of mononuclear 
non-granular elements in the blood of the enfeebled and poorly- 
nourished than in that of the active and vigorous individual. 

Similar changes are frequently associated with the terminal 
stages of a number of diseases, and may be found after hemorrhage 
from various causes — trauma, hemophilia, and purpura. 

Lymphocytosis, sometimes decidedly marked, is common in 
certain of the severe anemias, especially in chlorosis, pernicious 
anemia, and in syphilitic and tuberculous secondary anemias ; it 
may be observed during the course of a few of the acute infections, 
such as enteric fever, malarial fever, Malta fever, scarlet fever, 
measles, pertussis, variola, pulmonary tuberculosis, and pneu- 
monia. 

Diseases involving the spleen and lymphatic glands are often the 
cause of a varying degree of increase in the lymphocytes, common 
examples of such conditions being chronic malarial splenic tumors ; 
simple, syphilitic, and tuberculous adenitis ; and malignant neo- 

1 Loc. cit. 



198 



THE LEUCOCYTES. 



plasms, especially sarcoma, of the lymph glands. Enlargement of 
the thyroid gland also may give rise to a similar blood picture. 

Distinct lymphocytosis has been observed by Wilkinson 1 after 
the injection of quinine hydrochlorate ; and by Perry 2 as the re- 
sult of administration of thyroid extract. It also follows the in- 
jection of tuberculin, and pilocarpine. 

From a clinical viewpoint, lymphocytosis is of value chiefly in 
the diagnosis of lymphatic leukemia. Marked absolute increase 
in the number of lymphocytes associated with enlargement of 
the lymphatic glands forms a pathognomonic picture of this 
disease. 

The recognition of a doubtful case of syphilis may be facilitated 
by the occurrence of lymphocytosis plus eosinophilia. 

V. EOSINOPHILIA. 

The term eosinophilia is used to denote an increase above the 
normal standard in the number of eosinophiles in the circulating 
blood, this change usually, but not necessarily, being associated 
with a coincident increase in the relative percentage of these cells 
to the other forms of leucocytes. Thus interpreted, eosinophilia 
is a condition of absolute increase, in contradistinction to a purely 
relative gain in percentage, to which the term is not strictly appli- 
cable. 

For the sake of uniformity, it is customary to speak of the per- 
centage of eosinophiles rather than of their actual number, but 
in order to determine accurately the presence or absence of 
eosinophilia, it is also essential in every instance to calculate the 
number of eosinophiles to the cubic millimeter of blood, from data 
obtained by a numerical estimate and a differential count of the 
leucocytes, thus : 

Total number of Percentage of eosinophiles to Total number of 
leucocytes x other forms of = eosinophiles 

per cb. mm. leucocytes. per cb. mm. 

The necessity for such a calculation is forcibly illustrated in 
spleno-medullary leukemia, since in this condition the relative 
percentage of eosinophiles is often well within the normal limits, 
and yet a striking degree of eosinophilia may exist. For example, 
in a given case of this form of leukemia, the blood count shows 
300,000 leucocytes per cubic millimeter with 5 per cent, of 

1 Loc. cit. 

2N. Y. Med. Record, 1896, vol. I., p. 289. 



EOSINOPHILIA. 



199 



eosinophiles. This percentage, interpreted into the actual number 
of cells, means an eosinophilia of 15,000 per cubic millimeter, or 
an increase of thirty-fold in excess of the highest normal figure. 
It is also true that a high percentage of eosinophiles does not neces- 
sarily imply eosinophilia, for a differential count showing, for ex- 
ample, 10 per cent, of these cells, with a total leucocyte count of 
5,000 per cubic millimeter, means 500 eosinophiles to the cubic 
millimeter, a count not exceeding normal. 

On the basis of a variation in the normal number of leucocytes 
of from 5,000 to 10,000 per cubic millimeter, the absolute num- 
ber of eosinophiles may range from 25 to 500 per cubic millime- 
ter in the blood of the healthy adult. An increase in excess of 
this maximum standard, regardless of the percentage indicated by 
the differential count, constitutes eosinophilia. 

Granting the accuracy of the current view that the hemic 
eosinophiles are purely myelogenous elements, their increase in 
the blood may be attributed to the influence of chemotaxis, prob- 
ably of a specific and selective character. Under the influence of 
such a stimulus the eosinophiles are attracted from, and, perhaps, 
overproduced by, the bone marrow, and are thrown into the gen- 
eral circulation in large numbers. It is also possible that to a 
slight extent their proliferation from like cells may occur in the 
blood-stream as well. 

Increase in the number of eosinophiles occurs as a physiolog- 
ical change myoimg infants, in women during the menstrual period, 
and after coitus. With these three exceptions, the presence of 
eosinophilia is always to be regarded as an evidence of some 
pathological condition. 

Once believed to be a pathognomonic sign of leukemia, in the 
light of more recent investigations eosinophilia is now known to 
be associated with diseases of almost every conceivable nature ; 
in fact, it has been reported in such a large number of conditions 
of such widely dissimilar pathogenesis that its value as a clinical 
sign must be largely restricted. Inasmuch as many of these re- 
ported instances of eosinophile increase lack verification, it can 
only prove confusing to give here a list of the many pathological 
states in which the change is reputed to have been observed. 
The following list, based upon the work of Cannon, 1 Zappert, 2 
Gollasch, 3 T. R. Brown, 4 von Noorden, 5 and others, includes only 

x Deut. med. Woch., 1892, vol. xviii., p. 206. 

2 Zeitschr. f. klin. Med., 1893, vol. xxiii., p. 227. Also Wien. klin. Woch., 
1892, vol. v., p. 347. 

3 Forschr. d. Med., 1889, vol. vii., p. 361. 

4 Bull, of the Johns Hopkins Hosp., 1897, vol. viii., p. 79. 

5 Zeitschr. f. klin. Med., 1892, vol. xx., p. 98. 



200 



THE LEUCOCYTES. 



those diseases in which eosinophilia is observed with a great de- 
gree of constancy. Such conditions are : — 

I. Diseases of the Skin. 

Dermatitis herpetiformis. 

Eczema. 

Leprosy. 

Lupus. 

Pellagra. 

Pemphigus. 

Prurigo. 

Psoriasis. 

Scleroderma. 

Urticaria. 

I I . Helminthiasis. 

Ankylostomiasis. 

Ascaris lumbricoides infection. 

Oxyuris vermicularis infection. 

Tenia mediocanellata infection. 

Trichiniasis. 

III. Diseases of the Bones. 

Hypertrophy. 
Osteomalacia. 
Malignant neoplasms. 

IV. Postfebrile. 

Malarial fever. 
Pneumonia. 
Rheumatic fever. 
Scarlet fever. 
Septicemia. 

V. Bronchial Asthma. 

VI. S pie no -medullary Leukemia. 

In addition to the conditions listed above, eosinophilia also 
occurs, but with less constancy, in some forms of the high-grade 

secondary anemia of childhood, in purpura, in hemorrhagic effusions, 
in gonorrhea, in syphilis, in malignant disease, and in fibrinous 
bronchitis. It is also seen in many cases of splenomegaly, and 
after splenectomy, its development under the latter circumstance 



EOSINOPHILIA. 



201 



being regarded as a compensator}' condition. An increase in the 
percentage of eosinophils has also been noted in conditions of 
starvation. In scarlet fever the eosinophiles usually persist, in 
spite of the coexisting polynuclear leucocytosis, and the same 
peculiarity may often be found in trichiniasis. 

Eosinophilia may be produced experimentally by the injection 
of a number of medicaments, such as antipyrin, camphor, nu- 
clein, phosphorus, pilocarpine, tuberculin, and many of the iron 
salts. 

Neusser 1 and his school have contended that eosinophilia is 
symptomatic of an extensive group of diseases, chiefly those in- 
volving the sympathetic nervous system, the sexual organs, and a 
long list of disorders which they attribute to the " xanthin dia- 
thesis." Most of these views have been unsubstantiated, many 
are misleading, and a few can be shown to be fanciful. Those 
who are inclined to investigate some of the remarkable claims 
made by Neusser as to the diagnostic and prognostic value of 
eosinophilia are referred to his original communication on the 
subject. 

Diminution in the number of eosinophiles occurs as a physiolog- 
ical process during digestion, and after active muscular exercise. 
It is observed usually in lymphatic leukemia, during the febrile 
stages of diphtheria, influenza, pneumonia, enteric fever, and septi- 
cemia, frequently after hemorrhage, and in the terminal stages of 
many diseases. The number of eosinophiles is said to be dimin- 
ished after castration. The writer has found a decrease or even 
absence of eosinophiles in the majority of cases of chlorosis 
and pernicious anemia. 

The chief clinical value attached to eosinophilia relates to its 
presence in trichiniasis, in which infection it has been shown to be 
a sign of great reliability. It may, however, fail to develop in 
this condition. 

In the diagnosis of an exanthema which is suggestive of either 
scarlet fever or of measles, eosinophilia points to the former dis- 
ease, for it does not occur in the latter. 

The association of eosinophilia and lymphocytosis constitutes a 
blood change which may be helpful in the recognition of an ob- 
scure case of syphilis. 

High percentages of eosinophiles in chlorosis, in pernicious 
anemia, and after hemorrhage are generally regarded as an evi- 
dence of good regenerative powers of the hemogenic organs, and 
are therefore of favorable import. (Rieder. 2 ) 

I Wien. klin. Woch., 1894, vol. vii., p. 737. 
2 Loc. cit. 



202 



THE LEUCOCYTES. 



VI. BASOPHILIA. 

Increase in the number of basophiles in the circulating blood 
is of rare occurrence, having been observed in but few diseases 
except the spleno-medullary variety of leukemia, in which this 
change is quite constant, and sometimes most striking ; the baso- 
philes in this disease may constitute 5 or even 10 per cent, of all 
forms of leucocytes. The increase may involve either the finely 
granular, or the coarsely granular (mast cell) forms, or both, 
usually the latter. 

Up to the present time but little attention has been paid by 
hematologists to the general circulatory form of basophilia, al- 
though the local increase of the basophiles under various con- 
ditions has been well investigated. Canon 1 has reported an in- 
crease of the mast cells in a case of chlorosis, and in various skin 
diseases. Sherrington 2 has observed a similar blood change in 
patients dying in the reaction stage of Asiatic cholera. A. E. 
Taylor 3 states that he has seen a notable circulatory basophilia 
in a case of carcinoma, with marked cachexia, but without bone 
metastases ; in a case of gonorrhea ; in a case of mycosis fun- 
goides ; and in two cases of septic bone disease. Basophilia has 
also been observed in some cases of splenic anemia. 

Owing to our imperfect understanding of this condition, no 
theory regarding the production of basophilia is as yet generally 
acceptable. It is possibly due to the influence of a specific 
chemotactic substance, in response to which the basophiles are 
attracted from the bone marrow, and enter the general circula- 
tion. 

VII. MYELEMIA. 

The presence in the circulating blood of myelocytes, in small 
or in large numbers, is known as myelemia. As previously re- 
marked, this condition is invariably to be regarded as patholog- 
ical, since myelocytes are never found in the blood of the normal 
individual. 

The most striking example of myelemia is to be found 
in the spleno-medullary form of leukemia, in which condition this 
change constitutes one of the most conspicuous features of the 
blood-picture. Myelocytes occur in the blood in this disease in 
greater absolute and relative numbers and with greater constancy 

!Deut. med. Woch., 1892, vol. xviii., p. 206. 

2 Proc. of the Roy. Soc. London, 1894, vol. lv., p. 189. 

3 " Contributions from the William Pepper Laboratory of Clinical Medicine," 
Phila. , 1900, p. 148. 



LEUCOPENIA. 



203 



than in any other condition — a fact which is of the greatest diag- 
nostic value. The degree of increase may be enormous, as illus- 
trated by a case of the author's, in which the actual number of 
myelocytes was found to be 192,738 per cubic millimeter, or 
27.3 per cent, of all forms of cells in a total leucocyte count of 
706,000. 

Less frequently myelocytes are observed in lymphatic leu- 
kemia and in Hodgkiu 's disease, but in these conditions their 
occurrence is inconstant and their increase trivial. Small num- 
bers of myelocytes (from .5 to 2 or 3 per cent.) are found in 
almost every case of primary pernicious anemia, and are not un- 
common in marked cases of chlorosis and in many of the severe 
forms of secondary anemia due to various causes. They are fre- 
quently met with in such conditions as pneumonia, septicemia, 
diphtheria, syphilis, malignant disease, rachitis, tuberculosis, osteo- 
myelitis, osteomalacia, Addison 's disease, and the malarial fevers. 
The writer has found them also in the following conditions : car- 
bon monoxide poisoning, hepatic cirrhosis, acute gout, malignant 
endocarditis, exophthalmic goitre, as well as in the above-named 
affections. One is forcibly impressed with the almost constant 
presence of myelocytes in the estivo-autumnal type of malarial 
fever, in severe septic infections, and in enteric fever in childhood, 
both in the early stages of the disease and during the later, post- 
febrile anemic period. Small numbers of myelocytes have been 
reported also in many other conditions, chiefly those associated 
with leucocytosis, with anemia, or with both. 

Increased activity of the bone marrow, whereby the myelocytes 
are forced into the blood-stream, is in all probability responsible 
for the production of myelemia. In response to an increased 
demand for leucocytes, the marrow becomes so over-stimulated 
that many immature forms of leucocytes, or myelocytes, acciden- 
tally find their way into the general circulation, their passage from 
the marrow no doubt being accomplished largely by emigration. 
It is furthermore now believed that substances which are posi- 
tively chemotactic for the polynuclear neutrophiles also exert a 
similar attractive influence upon their immediate precursors, the 
myelocytes, stimulating their increased proliferation in the bone 
marrow and exciting their emigration from this tissue into the 
blood-stream. 

VIII. LEUCOPENIA. 

Decrease below the normal standard in the number of leuco- 
cytes in the peripheral blood is known as leucopenia or hypoleuco- 
cytosis. Such a condition, like its antithesis, leucocytosis, may be 



THE LEUCOCYTES. 



the result of either physiolgiocal or pathological causes. Owing 
to the variation in the normal number of eucocytes in different 
individuals, it is difficult to determine arbitrarily just what degree 
of decrease may be considered as a leucopenia, but it is safe to 
apply the term to any leuecocyte count decidedly below 5,000 
cells to the cubic millimeter. The number of leucocytes is rarely 
reduced to less than 3,000, except in certain of the essential 
anemias, in which their decline to one-tenth the maximum normal 
figure or even less, is occasionally to be observed. The most 
extreme instance of leucopenia on record has been reported by 
Koblanck, 1 who found but a single leucocyte in a careful search 
through twenty stained cover-glass preparations of blood from a 
man, of twenty-five years, suffering from epilepsy ; the exacty 
numerical estimate of the leucocytes in this case is not given in 
detail. 

The decrease may be accompanied by no deviation from the 
normal percentages of the different varieties of leucocytes, or it 
may involve a more or less decided gain in the lymphocytes, the 
latter being the more common change of the two. 

Accoding to the nature of its underlying causes, leucopenia 
may be considered clinically as either physiological or as patho- 
logical. 

Physiological Leucopenia. 

The decrease in the number of leucocytes observed in several 
physiological states is generally attributed to vasomotor influ- 
ences which produce changes in the distribution of the leucocytes 
throughout the system. Such changes occur from the effect of 
prolonged cold, and brief hot, baths. 2 Decastelle 3 has found that 
a temporary leucopenia may be produced experimentally, by stim- 
ulation of sensory nerves, this procedure causing a reflex con- 
traction of the abdominal vessels and a consequent retention of 
large numbers of circulating leucocytes in this part of the vascu- 
lar system. The variations in the number of cells ranges from 
twenty to thirty per cent, of the original count ; the maximum 
decrease occurs usually within three or four minutes, and in most 
instances does not persist longer than ten or fifteen minutes. 
Reduction of blood-pressure is promptly followed by a very transient 
diminution in the leucocytes of the peripheral blood. 

Malnutrition and starvation are also potent factors in the pro- 
duction of leucopenia, the decrease dependent upon such causes 
frequently being most pronounced. The much-cited case of the 

1 Inaug. Dissert., Berlin, 1889. 

2 Winternitz : loc. cit. 

3 Wien. klin. Woch., 1899, vol. xii., p. 395. 



LEUCOPENIA. 



faster, Succi, is a good example of the effects produced upon the 
leucocytes by abstinence from food. Luciani 1 found in the blood 
of this individual a decrease in the number of leucocytes from 
14,530 to 861 per cubic millimeter after a seven days' fast; on 
the eighth day an increase to 1,530 occurred, this being the 
average count noted during the remaining twenty-two days of 
the fast. The subnormal leucocyte counts which are often met 
with in many of the infirm and the greatly enfeebled can be 
traced to the effects of faulty nutrition, and to the malassimila- 
tion of food. 

Pathological Leucopenia. 

Leucopenia, or at least an absence of leucocytosis, occurs dur- 
ing the course of a number of general infectious diseases, promi- 
nent among which are the following : enteric fever, measles, in- 
fluenza, leprosy, Malta fever, the malarial fevers, and various 
forms of non-septic tuberculosis. In certain of the acute infections 
which are ordinarily accompanied by leucocytosis the combined 
influences of an intense infection and feeble resisting powers on 
the part of the individual may produce a distinct leucopenia, or 
may prevent the development of the characteristic increase. This 
is well illustrated by the low counts which sometimes are found 
in severe cases of pneumonia and of appendicitis. 

Leucopenia, often pronounced, is not uncommon in chlorosis 
and in pernicious anemia, being much more frequent and more 
decided in the latter disease. A well-marked leucopenia may be 
expected in about one-fourth of all cases of chlorosis, and in 
quite three-fourths of cases of pernicious anemia. It is also often 
met with in some high-grade secondary anemias, notably in those 
due to syphilis and to rachitis, and in splenic anemia. 

D'Orlandi 2 has called attention to the frequency with which 
leucopenia is observed in certain of the severer forms of chronic 
gastro-enteritis in young infants. 

In the anemias accompanied by a decrease in the leucocytes, 
especially in primary pernicious anemia, the rule holds good that 
the more intense the oligocythemia and oligochromemia, the 
greater the degree of leucopenia. Ehrlich 3 attributes the de- 
crease in such cases to a lessened proliferative function of the 
bone marrow, in consequence of which there is a diminution in 
the output of leucocytes by this organ. 

1 " Das Hungern " (German translation by O. Frankel), Hamburg and Leipzig, 
1890. 

2 Rev. Mensuelle des Malad. del'Enfance, 1899, vol. xvii., p. 300. 
3 Loc. cit. 



206 



THE LEUCOCYTES. 



In leukemia an acute intercurrent infection may produce an 
abrupt and marked fall in the number of leucocytes, as in Cabot's 
remarkable case of lymphatic leukemia, 1 in which, as the conse- 
quence of a fatal septicemia, the leucocytes fell in three weeks 
from 40,000 to 419 per cubic millimeter. 

Decrease in the number of leucocytes may be caused experi- 
mentally, by the administration of various drugs and other sub- 
stances. Bohland 2 found that it followed the injection of ergot, 
sulpho?ial, tannic acid, camphoric acid, atropine, agaracine, and 
picrotoxine. Delezene's 3 investigations showed that a marked 
decrease results from the injection of various anticoagulant sub- 
stances, such as peptone, diastase, and eel-serum; he attributes 
the leucopenia thus produced to two factors — actual destruction 
in the circulation of some of the leucocytes, and dilatation of the 
blood-vessels in which the undestroyed cells tend to accumu- 
late. The transient leucopenia which precedes an increase in 
the leucocytes has been discussed elsewhere. (See page 185.) 

iLoc. cit. 
2 Loc. cit. 

3 Nouveaux Montpel. Med., 1898, nrs. 31-34. 



SECTION V. 



DISEASES OF THE BLOOD. 



SECTION V. 



DISEASES OF THE BLOOD. 



I. CHLOROSIS. 

The blood drop is exceedingly pale and watery - 
Appearance looking, and flows so abundantly from the punc- 
of the ture that it actually seems as if the whole mass 
Fresh Blood, of blood in the body must be increased ; a large- 
sized drop usually follows the slightest prick of 
the needle, in spite of the obviously anemic appearance of the 
patient — a marked contrast to the difficulty commonly experi- 
enced in pernicious anemia of obtaining enough blood for the 
examination. The blood spread out in a film over the finger is 
transparent rather than opaque, and its fluidity is most striking. 

Microscopical examination of the fresh film shows excessive 
pallor of most of the erythrocytes, together with the presence of 
a variable number of cells of smaller diameter than normal, in 
the average case, and of cells decidedly deformed in shape, in 
severe cases. The practised observer can determine at first 
glance that the number of erythrocytes is not greatly decreased, 
except in an occasional case in which the oligocythemia may be 
so marked as to lead him to infer that he is dealing with a well- 
defined secondary anemia. 

Coagulation of the blood drop, in spite of the 
Coagulation, fact that hyperinosis is absent, is generally very 
rapid in chlorosis, often so rapid as to interfere 
with the technique of the examination, if one delays during this 
procedure. 

The specific gravity of the whole blood is more 
Specific or less diminished, the degree of decrease being 
Gravity. closely parallel with the loss of hemoglobin. 

Lloyd Jones, 1 who has made elaborate researches 
concerning this subject, believes that chlorotic blood exhibits an 
exaggeration of the fall in specific gravity which occurs in healthy 
girls at about the age of puberty. In the 36 cases studied by 
this author the specific gravity ranged from 1030 to 1049, tne se 

1 " Chlorosis," London, 1897, p. 18. 

14 



2IO 



DISEASES OF THE BLOOD. 



figures corresponding to 17 and 58 per cent, of hemoglobin, re- 
spectively, as estimated by the von Fleischl hemometer. In 30 
cases Hammerschlag 1 found that the density of the whole blood 
averaged 1045, an d of the serum, 1030. 

Most obser- 

Fig. 37. Alkalinity, vers maintain 

that in this dis- 
— ^ ease the alkalinity of the whole 

blood generally remains normal, 
0|T^ o O or suffers but a trifling diminu- 

O t * on ' ^ S ^ e ^ n ^ * n direct contrast 

\J r\ ^tJ *° ^ e con dition f° un d in other 

f JZ~ vf^O forms of anemia, in which the 

^ s '"" { \ fal1 in the alkalinity figure is 

i I 0 J; O * ^ usually pronounced. Burmin, 2 
f^v fj^| O in 1 8 examinations of 9 cases, 

O^^D- ^ X found that it ranged between 

0.128 and 0.200 grm. NaOH, 
Changes in the erythrocytes in the normal figures of this inves- 

chlorosis. (Triacid stain.) .. , u • , o~ „ T o 

ti^ator being 0.182 to 0.2 1 8 grm. 

Showing a general decrease in the diameter ° n 0 • t . . 

of the corpuscles, striking decolorization, and 111 6 OI these Cases the adminiS- 

moderate poikilocytosis. The nucleated cell ... r • r 11 1 i 

near the center of the field is a normoblast. tratlOn of iron WaS followed by 

a marked increase in the alkalinity 
of the blood, closely paralleling the gain in hemoglobin and ery- 
throcytes. On the other hand, Graeber 3 states that in many cases 
he discovered abnormally high alkalinity figures, so constantly, 
indeed, that he regarded them as " specific for this condition." 

The decrease in the percentage of hemoglobin 
Hemoglobin is usually excessive in comparison with the re- 
and duction in the number of erythrocytes, this dis- 
Erythrocytes. proportionate oligochromemia being the most 
conspicuous and most constant feature of the 
changes affecting chlorotic blood. Naturally, such a change 
gives rise to very low color indices. This statement applies only 
to the majority of cases, for a low color index, while it is the rule 
in chlorosis, and is, diagnostically, a most important feature of 
the blood-picture, is by no means invariably found — no more in- 
variably than a high color index in pernicious anemia. To illus- 
trate this point, it will be observed that of the 106 cases of chlo- 
rosis blood counts collected in Table I., 49 (or more than 46 per 
cent.) showed an index below 0.50, the average for the series 

1 Wien. Med. Presse, 1894, vol. xliv., p. 1068. 
2 Zeitschr. f. klin. Med., 1900, vol. xxxix., p. 365. 
3 "Zurklin. Diag. d. Blutkrankheit," Leipzig, 1890, p. 289. 



CHLOROSIS. 



211 



being 0.51, the maximum 1.01, and the minimum 0.22. In this 
table are given the "first counts," or those made when the 
patient first applied for treatment. 

The average loss of hemoglobin, as evidenced by this same 
series of cases, amounts to a trifle less than 60 per cent., in con- 
trast to which stands the mean average erythrocyte decrease, 
which is equivalent to about 20 per cent., the hemoglobin loss 
thus averaging about three times as great as that of the corpus- 
cles. Individually, the hemoglobin percentage ranged in these 
cases from 12 to 75, averaging 41.3, and the count of erythro- 
cytes from 1,720,000 to 5,600,000, averaging 3,876,712. On 
account of their rather close correspondence, it is interesting to 
compare with these figures the results obtained by Cabot 1 in 
109 cases and those of Thayer 2 for 63 cases. Cabot's cases 
gave the following mean averages : hemoglobin, 41.2 per cent.; 
erythrocytes, 4,112,000, with individual counts ranging from 
1,932,000 to 7,100,000. In Thayer's series the hemoglobin 
averaged 42.3 per cent, and the erythrocyte count 4,096,544. 
Somewhat lower figures are given by Bramwell, 3 who found the 
following averages in a series of 80 cases : hemoglobin, 34 per 
cent., or from 10 to 60 per cent.; erythrocytes, 3,437,300, or 
from 1,425,000 to 5,200,000 per cubic millimeter; and color 
index, 0.49, or from 0.20 to 0.96. 

While numerous examples may be found in Table I. of typ- 
ical cases of chlorosis in which the hemoglobin estimate and ery- 
throcyte count resemble those commonly occurring in pernicious 
anemia or in the secondary anemias, nothing is more characteris- 
tic of chlorosis than the averages above mentioned. The great 
difference is between chlorosis and pernicious anemia, the index 
usually being high and the corpuscular loss extreme in the latter 
disease. As compared with the secondary anemias, the differ- 
ence is too slight and its occurrence too inconstant to enable one 
to regard it with any degree of certainty from a clinical standpoint. 
Theoretically, in secondary anemia the hemoglobin loss is fairly 
proportionate to the erythrocyte decrease, thus producing color 
indices at or somewhat below the normal, but cases of secondary 
anemia having a so-called " chlorotic " type of blood are far too 
common to render any information reliable gained by a sim- 
ple inquiry into the changes affecting the erythrocytes and their 
hemoglobin content. 

1 Loc. cit. 

2 Cited by Osier: "American Text-book of Theory and Practice of Medicine," 
Phila., 1894, vol. ii., p. 196. 

3 "Anemia," etc., London, 1899, p. 35. 



Table I. 

Hemoglobin, Erythrocytes, and Leucocytes in Chlorosis, at the First 
Examination. 106 Cases. 





.s «• 




a s 


en S 




.9 « 




en . 

« E 


SC £ 




jz bo 

O 


i) 
a 




M 




Hemoglob 
Percentag 


T3 
C 




£6 


Num 


Hemog 
Percer 


Color I 


Erythn 
per cb. 


Leucoi 
per cb. 


Num 


Color I 


Erythn 


Leuco 
| per cb. 


I 


55 


• 49 


5,600,000 


6,O0O 


54 


25 


.32 


3,910,000 


6,000 


2 


65 


•59 


5,500,000 


12,000 


55 


3° 


•38 


3,890,500 


6,000 




65 


•59 


5,500,000 


9,000 
II,8oo 


56 


3° 


•39 


3,882,000 


7,000 


4 


45 


.41 


5,420,000 


57 


65 


.84 


3,88o,000 
3,80O,O0O 


4,000 


5 


35 


•33 


5,300,000 


3,000 


58 


50 


.66 


15,000 


6 


35 


.33 


5,200,000 


2I,000 


59 


4° 


•53 


3,800,000 


9,37° 


7 


7 1 


.68 


5, 180,000 


7,5°° 


60 


38 


.50 


3,780,000 


9,5°° 


8 


65 


•63 


5,140,000 


4,500 


61 


62 


•83 


3,750,000 


8,000 


9 


65 


•63 


5,100,000 


6,000 


62 


40 


•53 


3,750,000 


6,400 


IO 


45 


•44 


5,080,000 


6,000 


63 


35 


.46 


3,750,000 


8,333 


ii 


70 


.70 


5,000,000 


5,000 


64 


3° 


.40 


3,735,000 


12,400 


12 


55 


•55 


5,000,000 


4,200 


65 


75 


1. 01 


3,700,000 


8,000 


J 3 


5 2 


• 5 2 


5.000,000 


7,000 


66 


43 


•58 


3,700,000 


5,000 


14 


65 


.66 


4,870,000 
4,860,000 


3,000 


67 


20 


.27 


3,685,000 


4,000 


15 


40 


.41 


8,500 


68 


40 


•55 


3,624,000 


9,000 


16 


65 


.67 


4,800,000 


6,000 


69 


3 1 


•43 


3,6lI,O0O 


3,4oo 


17 


60 


.62 


4,800,000 


5,600 


7° 


58 


.81 


3,600,000 


8,000 
7,680 


18 


5° 


•5 2 


4,800,000 


10,000 


7 1 


44 


.61 


3,600,000 


J 9 


60 


.64 


4,660,000 


2,000 


72 


40 


•56 


3,550,000 


2,000 


20 


55 


•59 


4,640,000 


7,000 


73 


34 


.48 


3,550,000 


4,600 


21 


45 


.48 


4,625,000 


5,000 


74 


28 


•39 


3,540,000 


7,800 


22 


60 


•65 


4,600,000 


12,000 


75 


33 


•47 


3,520,000 


8 000 


2 3 


45 


.48 


4,600,000 


6,000 


76 


42 


.60 


3,500,000 


9,000 
4,800 


24 


55 


.60 


4,560,000 


9,000 


77 


38 


•54 


3,500,000 


25 


60 


.66 


4,520,000 


I7,000 


78 


3° 


•43 


3,500,000 


17,000 


26 


40 


•44 


4,520,000 


I4,000 


79 


3° 


•43 


3,500,000 


7,100 


27 


5° 


•55 


4,500,000 


7,000 


80 


35 


•55 


3,200,000 


8,000 


28 


40 


•44 


4,500,000 


4,000 


81 


23 


•36 


3,200,000 


5,000 


29 


20 


.22 


4,500,000 


ll,000 


82 


20 


.31 


3,200,000 


9,000 


30 


43 


.48 


4,400,000 


7,000 


83 


2 5 


.40 


3,100,000 


4,000 


31 


40 


•45 


4,400,000 


9, COO 


84 


20 


.32 


3,100,000 


5,ooo 


32 


3° 


•33 


4,400,000 


5,000 


85 


38 


0 


3,000,000 


4,5oo 


33 


60 


.68 


4,391,000 


4,200 


86 


3° 


.50 


3,000,000 


4,000 


34 


65 


•74 


4,380,000 


7,400 


87 


27 


•45 


3,000,000 


6,000 


35 


43 


•49 


4,320,000 


8,000 


88 


20. 


•34 


2,912,000 


2,500 


36 


33 


•38 


4,320,000 


11,200 


89 


28 


.48 


2,900,000 


4,000 
7,480 


37 


45 


.52 


4,300,000 


6,000 


9° 


21 


.37 


2,844,000 


38 


52 


.61 


4,240,000 


8,000 


91 


20 


•36 


2,800,000 


10,000 


39 


34 


.40 


4,230,000 


2,400 


92 


2 7 


.48 


2,780,O00 


8,000 


40 


65 


•77 


4,210,000 


9,200 


Q7 




60 


2, 770, OOO 


9,000 


41 


58 


.69 
• 65 


4,204,000 


3,500 


94 


20 


^6 


2,740,000 


2,700 


42 


55 


4,200,000 


5,000 


95 


22 


• 41 


2,660,000 


12,000 


43 


50 


•59 


4,200,000 


4,000 


96 


26 


•49 


2,630,000 
2,600,000 


2,400 


44 


38 


•45 


4, 200,000 


8,000 

6,800 


97 


2 3 


•44 


8,400 


45 


50 


•59 


4,190,000 


98 


22 


.42 


2,600,000 


12,000 


46 


50 


.60 


4,150,000 


5,000 


99 


46 


•95 


2,420,000 


8,000 


47 


60 


•73 


4, 100,000 


5,000 


100 


22 


.46 


2,400,000 


6,IOO 


48 


45 


•55 


4,070,000 


6,500 


101 


17 


.36 


2,350,000 


4,000 
6,IOO 


49 


55 


.69 


4,000,000 


4,000 


102 


30 


.70 


2,I38,O0O 


5o 


50 


.62 


4,000,000 


3,050 


103 


30 


•7i 


2,100,000 
2,o8o,000 


6,000 


51 


45 


•56 


4,000,000 


15,000 


104 


30 


.72 


4,000 


52 


40 


•5o 


4,000,000 


9,500 


105 


18 


•5o 


1,800,000 


2,IOO 


53 


27 


•34 


4,000,000 


8,000 


106 


12 


•35 


1,720,000 


3,000 




Aver. 


41.3 


0.51 


3> 8 76,7i 2 


7,090 



CHLOROSIS. 



213 



The most conspicuous change to be observed in the stained 
film of chlorotic blood is the presence of large numbers of under- 
sized, pale erythrocytes, such cells usually being so numerous 
that one is forcibly impressed with the fact that there must be a 
general decrease in the average diameter of all the eiythrocytes 
in the field. As a rule, this decrease in size involves a large 
number of corpuscles moderately, rather than a few to an ex- 
treme degree, and therefore, except in severe cases associated 
with marked oligocythemia, striking examples of microcytosis are 
wanting. This alteration is just the opposite of what is generally 
found in pernicious anemia, for in this disease a tendency to- 
ward an increase in the average diameter of the erythrocytes, 
frequently in association with the presence of many extremely 
small microcytes, is the rule. If well defined, this feature of the 
blood changes carries a certain amount of diagnostic significance, 
although it cannot be distinguished in every case of chlorosis, 
since in some the diameter of the erythrocytes appears to be 
unaltered, while in others the deformities of size may so affect the 
cells that the blood-picture resembles that of a severe secondary 
anemia. 

The pallor of the erythrocytes, shown by their feeble reaction 
toward the plasma stain, is at once apparent. The great majority 
of the cells are affected alike, being pale, often quite colorless in 
the center and gradually becoming of darker color toward the 
periphery, in which a certain amount of hemoglobin still remains. 
This portion of the cell is usually well stained, so that the cor- 
puscles frequently appear as hoops or rings ; some, however, do 
not show even this narrow hemoglobin-filled zone, being practi- 
cally decolorized throughout. Stroma degeneration, as shown by 
the changes described by Maragliano, is not demonstrable in the 
average case of moderate severity, but this process has been ob- 
served in occasional cases of high grade. Polychromatophilia, 
except in cases of the latter class, does not occur. 

Basophilic granulations in the erythrocytes are not found in 
this condition, according to Grawitz. 1 

Deformities of shape are not noticeable, as a rule, except in 
the severer types of the disorder. In such cases, in which both 
the hemoglobin and the cellular losses are excessive, poikilo- 
cytosis may be very striking, as great, in fact, as in any blood 
disease, not excepting pernicious anemia. Poikilocytes, should 
they occur, are almost invariably of small size. 

Nucleated erythrocytes are very rare. In the average case 
they are usually sought for in vain, and even in the severer forms 

1 Loc. cit. 



214 



DISEASES OF THE BLOOD. 



of chlorosis these cells are not numerous. Erythroblasts con- 
forming to the normoblastic type are found almost exclusively ; 
megaloblasts, although they are seen now and then, are ex- 
tremely uncommon, and have never been found in a large relative 
or absolute proportion to the other form of nucleated erythrocytes. 

The number of leucocytes per cubic millimeter 
Leucocytes, is, as a rule, normal in the typical case of chloro- 
sis. If leucocytosis occurs, as it does occasion- 
ally, it should be attributed to some hidden or frank complication ; 



Table II. 

Qualitative Changes in the Leucocytes in Chlorosis, at the First 
Examination. 37 Cases. 



Case No. 


Small Lymph- 
ocytes. 


Large Lymph- 
ocytes. 


Polynuclear 
Neutrophiles. 


Eosinophiles. 


Myelocytes. 


j 


16.O 


6.0 


76.O 


2.0 


Q 


2 


1 1 O 


-7 r\ 


8c c 






J 


20. 0 


1 c 

O'J 


7C O 


1 e 


O 


4 


0 C r> 
^3 • u 


3- u 


72.O 


0. 0 


O 


C 


IQ C 


20 ? 


60.O 


0.0 


O 


6 


22 1; 




62 <; 


0.0 


O 


7 


20 z 


I9.O 


60.5 


0.0 


O 


8 


11 1 


17 8 


50.0 


0.0 


O 


0 


*O0 


16.O 


C7 C 


1.0 


O 


10 


tS c 
IS.5 


I2.0 


°9-5 


0. 0 


O 


1 1 


18.O 


IO. O 


t> 0 


0, 0 


O 


12 


17.O 


21.5 


61.5 


0.0 


O 


13 


19-5 


I7.0 


63.O 


0.5 


O 


J 4 




T /I f 

M~ 5 


°3-5 




O 


15 


7-5 


12.4 


80.1 


0.0 


O 


16 


19-3 


21. 1 


59-6 


0.0 


O 


17 


18.5 


16.O 


65.5 


0.0 


O 


18 


18.0 


16.O 


65.0 


1.0 


O 


19 


18.3 


I9.O 


61.0 


1.7 


O 


20 


15-5 


24-5 


60.0 


0.0 


O 


21 


26.0 


21.0 


53-o 


0.0 


O 


22 


12.0 


30.0 


58.0 


0.0 


O 


23 


13-5 


12.5 


73-5 


o-5 


O 


24 


14.0 


15.9 


70.1 


0.0 


O 


25 


17.5 


14.0 


68.5 


0.0 


O 


26 


15.0 


17.0 


68.0 


0.0 


O 


27 


20.5 


"5 


68.0 


0.0 


O 


28 


20.3 


12.7 


67.0 


0.0 


O 


29 


31.0 


9.0 


60.0 


0.0 


O 


30 


35-9 


6.0 


58.0 


O.I 


O 


3i 


24.0 


2.0 


74.0 


0.0 


O 


32 


27-5 


40.0 


32.0 


o-5 


O 


33 


26.0 


15.0 


56.0 


1.0 


2 


34 


24.0 


26.0 


50.0 


0.0 


O 


35 


22.0 


6.0 


72.0 


0.0 


O 


36 


24-5 


14.5 


61.0 


0.0 


O 


37 


6.0 


32.0 


59-o 


0.0 


3 


Average 


: 20.I 


15-5 


64.0 


•31 


•13 



CHLOROSIS. 



215 



if leucopenia exists, as it sometimes does, it may nearly always 
be regarded as a sign of the severity of the disease, since it is 
rarely met with except in cases in which the hemoglobin and ery- 
throcyte losses are decidedly marked. The mean average num- 
ber of leucocytes in the 106 cases of chlorosis to which reference 
has already been made (Table I.) is 7,090 per cubic millimeter, 
or approximately the same as the average count of these cells in 
normal blood. Counts as low as 2,000 and as high as 21,000 
were made in this series; and in 14 of the cases (or 13.2 per 
cent.) the increase was sufficiently in excess of the normal stan- 
dard to justify the application of the term leucocytosis, that is, it 
was in excess of 10,000. These figures do not differ materially 
from those of Cabot and of Thayer, alluded to above, Cabot's 
counts in 104 cases averaging 7,400, and Thayer's estimates in 
63 cases being but slightly greater, 7,485. 

Relative lymphocytosis, usually marked in relation to the se- 
verity of the case, is a common, but not a constant, qualitative 
change. It occurs in both mild and severe cases, but is much 
more common in the latter. In the author's experience, this in- 
crease involves chiefly the larger forms of these cells, both the 
non-granular mononuclear cells with spherical nuclei and the so- 
called " transitional " forms with indented nuclei; striking in- 
crease in the last named variety of cells was a notable differential 
change in a large proportion of the 37 cases listed in Table II. 
In many of the cases in this series the large and small lympho- 
cytes together made up from 45 to as high as 67.5 per cent, of 
all varieties of leucocytes, the percentage of large forms being 
repeatedly estimated at 20 or 30, and even 40, in one instance. 

Deviations from normal in the relative percentage of poly?iu- 
clear neutrophiles are governed by the behavior of the lympho- 
cytes, low differential counts of the former type of cells accom- 
panying high percentages of the latter, and vice versa. Should 
leucocytosis exist, it is of the pure polynuclear neutrophile type. 

The eosinophiles are notably decreased, both absolutely and 
relatively. The author has never found an increase of these cells 
in chlorosis, although considerable pains were taken to verify the 
statements made by some writers that this variety of leucocytes 
is occasionally observed to be greatly above normal in this con- 
dition. Eosinophiles were absent entirely in more than seven- 
tenths of all the cases collected in Table II., and were never found 
to exceed 2 per cent, of all the forms of leucocytes. 

Exceptionally, small percentages of myelocytes may be en- 
countered, as a rule, only in cases of a severe character. These 
cells are ordinarily present in not more than 6 per cent, of all 



2l6 



DISEASES OF THE BLOOD. 



cases, and their relative proportion to the other forms of leuco- 
cytes is always trifling, being rarely over I or 2 per cent. 

In the great majority of cases it has been gen- 
Blood Plaques, erally observed that the number of plaques is 
considerably in excess of normal. It appears 
that these elements are especially numerous in blood which clots 
rapidly. 

The changes in the blood associated with most 
Diagnosis, well-defined cases of chlorosis may be summarized 
as follows : 



Color. 

Coagulation. 
Specific gravity. 
Hemoglobin. 

Erythrocytes. 



Pale and watery. 
Usually rapid. 
Decreased. 

Marked absolute decrease, in most instances 
relatively greater than the loss of erythrocytes, 
thus producing a low color index. 

Moderately decreased, ordinarily to about 
4,000,000 per cubic millimeter. Counts of 
3,000,000 and less are common in severe cases. 
Erythroblasts very rare ; if present, cells of 
the normoblastic type invariably predominate. 
General decrease in the average diameter of 
the erythrocytes. In severe cases microcy- 
tosis may be marked. 

Poikilocytes not numerous, except in severe 
cases. 

Polychromatophilia rare. 

Usually normal in number. 
Relative lymphocytosis common. 
Small percentages of myelocytes, only in severe 
cases. 

Eosinophiles notably decreased. 

Plaques. Increased in number. 

He who would essay the diagnosis of chlorosis solely by the 
aid of the information derived from the blood examination is in- 
deed a rash clinician. This point cannot be emphasized too 
strongly, that there is no blood-picture peculiar to this condition, 
since^ changes precisely similar to those seen in many a case of 
typical chlorosis are often observed in the secondary anemias, 
especially in those dependent upon such factors as syphilis, tuber- 



Leucocytes. 



CHLOROSIS. 



217 



culosis, malignant disease, and chronic renal lesions. On the 
other hand, rare cases of chlorosis have been reported in which 
no alterations in the blood were discoverable. The blood changes 
enumerated above (especially such features as a low color index, 
the general decrease in the diameter of the erythrocytes, the ab- 
sence or scantiness of erythroblasts, and the normal number of 
leucocytes associated with relative lymphocytosis and a decrease 
of the eosinophiles) are not then, pathognomonic, but simply 
highly suggestive of the disease under discussion, in view of 
which fact it becomes essential to seek for other clinical signs 
and to consider them carefully in connection with the blood find- 
ings. One of the most important points which should be borne 
in mind is the fact that chlorosis is practically confined to females, 
usually those in early womanhood, at or near the period of 
puberty 7 . Chlorosis is about as compatible with the male sex as 
is pregnancy — the so-called " male chlorosis " is nothing more 
than a diagnostic myth. Osier 1 remarks that in girls in whom 
the disease occurs early in their teens precocity and almost prema- 
ture appearance of the menses is likely to exist. A large propor- 
tion of those in whom the disease develops later in life complain 
of scantiness or total suppression of the menstrual flow and of 
dysmenorrhea, these symptoms being especially common in chlo- 
rotics in the early twenties or thereabouts. 

The question of heredity also is of some diagnostic value, for 
it has been frequently noted that the disease exists, for instance, 
in two or more sisters, the statement being elicited upon further 
inquiry that their mother suffered from chlorosis at an earlier 
period. Thus, Albutt 2 speaks of meeting in his consulting-room 
the chlorotic daughters of women whom years before he had 
treated for the same disorder. 

Among the other manifestations of the disease to which atten- 
tion should be paid the following are the more important : a pecu- 
liar greenish-yellow color of the complexion and blanching of the 
mucous membranes (except in those rare instances of chlorosis 
florida, in which the color is high) ; the occurrence of various 
gastro-intestinal disturbances, of edema of the face and lower 
limbs, of vertiginous attacks, and of dyspnea upon physical exer- 
tion ; and the presence of systolic basic heart murmurs, and a 
venous hum most distinctly audible over the great vessels of the 
neck. Slight enlargement of the thyroid gland, frequently asso- 
ciated with Joffroy's sign (absence of horizontal wrinkling of the 
skin of the forehead and of upward curving of the eye-brows, when 

1 Loc. cit. 

2 " System of Medicine," London and N. Y., 1898, vol. vi., p. 483. 



218 



DISEASES OF THE BLOOD. 



the patient glances suddenly at the ceiling without elevating her 
head), is a physical sign which should always make one suspicious 
of chlorosis. 

The distinctions between chlorosis and pernicious anemia, as 
shown by the blood examination, will be described under the 
latter disease. (See page 230.) 

II. PERNICIOUS ANEMIA. 

In marked cases of pernicious anemia it is 
Appearance sometimes almost impossible to obtain from a 
of the puncture of the finger-tip a sufficient quantity of 
Fresh Blood, blood for an ordinary clinical examination, owing 
to the bloodlessness of the superficial vessels. 
This fact naturally prompts the query, Does an actual reduction 
in blood volume or oligemia exist in such an instance, or can the 
dryness of the superficial tissues be attributed to vasomotor dis- 
turbances causing an unequal distribution of the blood mass, in 
favor of the internal viscera and deeper circulation ? In a patient 
in whom puncture of the finger fails to give the requisite amount 
of blood, the lobe of the ear will generally be found to yield a 
drop of sufficient size. But even this very vascular part of the 
body may in extreme cases seem practically bloodless. The 
writer recalls a case of fatal anemia in which, in order to secure 
a drop of blood large enough to fill the lumen of an erythrocy- 
tometer only to the 0.5 graduation, it was necessary to open a 
small superficial vessel of the scalp, repeated deep punctures of 
the fingers, toes, and ear-lobes having given negative results. 

The drop as it emerges from the puncture wound is exceed- 
ingly pale, thin, and hydremic, lacking the characteristic opac- 
ity of healthy blood, and being of a fluidity and general color 
which have been likened to those of meat-washings. In an oc- 
casional instance the color of the blood may be practically normal, 
or, rarely, of a brownish-red or chocolate tint ; but, as a rule, it 
resembles a watery, pinkish fluid, which appears to be deficient 
both in depth of color and in density. It has been frequently 
observed that, after having stood for a short length of time, the 
drop shows a tendency to separate into two more or less distinct 
parts, consisting of a dark stratum of corpuscles and a clear, 
watery-looking layer of plasma ; or it may be irregularly mottled 
at different points, as if the corpuscles had become concentrated 
in isolated, compact groups in various parts of the plasma, thus 
producing the effect of alternating dark and light areas distributed 
through the drop. 



PERNICIOUS ANEMIA. 



219 



Microscopical examination of the fresh film shows a great re- 
duction in the number of the erythrocytes, together with the 
presence of many forms of these cells which exhibit every possible 
variation in size and in shape. The color of the individual eryth- 
rocyte varies, some being normally dark and well colored, 
while others appear as mere washed-out rings or " phantoms." 
In some of the cells the hemoglobin appears to be quite evenly 
distributed throughout the stroma, so that their typical biconcav- 
ity is obliterated. The endoglobular degenerative changes and 
those structural alterations denoting total necrosis of the eryth- 
rocytes, previously described, may be demonstrated with great 
clearness in this condition. Rouleaux formation is either entirely 
absent, or incomplete and atypical. 

Owing to the extreme oligocythemia common in pernicious 
anemia, it is advisable in making the films to use a somewhat 
larger drop of blood than is chosen for making ordinary spreads, 
so that the field will not contain such a pronounced scarcity of 
cellular elements. 

The obvious fluidity of the blood, the deficiency 
Coagulation, of the fibrin network, and the slowness with which 
coagulation occurs are marked features of this 
disease. In fact, in some cases coagulation may be said not to 
occur at all, according to the experiments of Hayem 1 and others 
of the French school, as in the case quoted by Lenoble, 2 in which 
no clotting of a sample of arterial blood was observed even after 
a lapse of seventy -two hours after its withdrawal from the ves- 
sels. Many authors attribute considerable diagnostic value to 
this absence of clotting, and others go so far as to state that it 
renders a patient suffering with pernicious anemia especially prone 
to troublesome hemorrhages, even from a slight finger-prick — an 
accident which must be extremely rare, however, for it practically 
never complicates an ordinary clinical examination. 

The density of the whole blood is much 
Specific below the normal standard, specific gravities as 
Gravity. low as 1027 having been reported. It is to 
be recalled that in cases with a high color in- 
dex erroneous results may occur from attempting to estimate 
the hemoglobin percentage by Hammerschlag's table of equiv- 
alents, since the hemoglobin, in reality, is somewhat higher 
than the percentages corresponding to the specific gravity figures. 
(See page 100.) 

1 Loc. cit. 

2 "Charact. semeiol. du caillot et du serum," Paris, 1898. 



220 



DISEASES OF THE BLOOD. 



Up to the present time, the reaction of the 
Alkalinity, blood in pernicious anemia has not been very 
thoroughly studied, but the work already accom- 
plished is sufficient to show that the alkalinity is much diminished, 
as in most severe anemias. That it may be strikingly below 
normal is shown by a case lately reported by Waldvogel, 1 who 
in one case estimated the alkalinity figure at .40 grm., using 
Salkowski's method. This author has determined that the nor- 
mal alkalinity for men ranges from .350 to .400 grm., and for 
women from .300 to .350 grm. 

Both the percentage of hemoglobin and the 
Hemoglobin number of erythrocytes are greatly diminished, 
and the former, as a general rule, relatively less so 
Erythrocytes, than the latter. Thus, inasmuch as the individual 
corpuscles contain often a normal or even an ex- 
cessive amount of hemoglobin, it follows that high color indices 
are common — common but by no means constant, as seems to be 
the current impression among many students, for although it is 
true that while the average color index is 1 .00 or higher in per- 
nicious anemia cases, the same statement cannot always be ap- 
plied to the individual case. The author's series of 31 cases 
(Table III.) showed, at the first examination, hemoglobin percent- 
ages varying from a minimum of 12 to a maximum of 45, with a 
mean average of 25.1; the color index of these cases ranged 
from 0.40 to 1.87, the average being 1.08; in 17 of the cases 
(or 54.8 per cent.) the figure was 1.00 or higher. During re- 
missions, as the erythrocytes increase, it is common to find low 
indices, this peculiarity being especially conspicuous should the 
improvement in the patient's condition be rapid, since in such 
instances the corpuscular increase is relatively much more rapid 
than the gain in hemoglobin. In cases in which improvement 
takes place more slowly, the color index is likely to remain 
higher, for here the corpuscles and the hemoglobin are more 
prone to increase proportionately along parallel lines. 

The oligocythemia is most striking, counts of from 1,000,000 
to 2,000,000 erythrocytes per cubic millimeter being not uncom- 
mon when the patient first comes under observation, the number 
of cells frequently diminishing to about 750,000 or even 500,000 
later during the course of the disease. In Quincke's often-quoted 
case the remarkable count of 143,000 per cubic millimeter was 
observed just before the death of the patient, an instance which 
is almost paralleled by a case recorded by Hills, 2 in which the 

1 Deut. med. Woch., 1900, vol. xxvi., p. 685. 

2 Boston Med. and Surg. Journ., 1898, vol. cxxxix., p. 542. 



PERNICIOUS ANEMIA. 



221 



erythrocyte count feil to 155,760 one day before death. In the 
series just mentioned (Table III.) the count of erythrocytes per 
cubic millimeter averaged 1,343,677, ranging between 550,000 
and 3,240,000 ; this represents an average loss in corpuscular 
matter of somewhat less than 75 per cent., the greatest decrease 
amounting to almost 90 
per cent, of normal — 
a much more striking 
oligocythemia than is 
found in any other form 
of anemia. 

Periods of temporary 
increase in the hemo- 
globin and erythrocytes, 
followed sooner or later 
by relapses, are com- 
monly observed, the 
gain during such peri- 
ods sometimes being 
verypronounced. Thus, 
in one of the cases tab- 
ulated below a gain of 
more than 2,500,000 
erythrocytes to the cu- 
bic millimeter was noted 
during a period of six 
weeks, with a subsequent 
loss of over 1 ,000,000 cells in the following eight days, the color in- 
dex during this time ranging from 1.25 to 0.74. These periods of 
improvement in the condition of the blood are generally asso- 
ciated with an amelioration of the other clinical manifestations of 
the disease, the patient's general condition improving so substan- 
tially that he begins to consider himself on the high road to re- 
covery, but in the course of time the old symptoms return, and 
the characteristic blood-picture again becomes evident. In most 
cases death is preceded by extreme oligochromemia and oligo- 
cythemia, the hemoglobin often falling to 1 5 or 20 per cent, of 
normal and the eiythrocyte count declining to 750,000 or less ; 
in some cases, however, these losses are not so marked, and the 
count does not fall below 1,500,000 during the whole course of 
the disease. 

A prominent characteristic of the blood in pernicious anemia 
is the wide dissimilarity in the size of the erythrocytes, due to the 
presence of large numbers of megalocytes and microcytes ; so 




Changes in the erythrocytes in pernicious 
anemia. (Triacid stain.) 

Showing a general increase in the diameter of the cor- 
puscles, and marked poikilocytosis. The nucleated cell in 
the right of the field is a megaloblast. 



222 



DISEASES OF THE BLOOD. 



Table III. 



Hemoglobin and Erythrocytes in Pernicious Anemia, at the First 
Examination. 31 Cases. 



Number. 


Hemoglobin Per Cent. 


Color Index. 


Erythrocytes percb. mm. 


I 


0 


.AO 


1 2AO OOO 


2 


V> 

jj 




3,008,500 




AO 


.81 


2,468,000 


A 
*t 


24. 


S2 


2,300,000 


c 

5 


2A 


•54 


0 inn 000 


6 


24 


.60 


2,000,000 


7 


26 


7 T 


I, 810,000 


8 


20 


r c 
• jj 


1,800,000 


Q 


AO 


I 23 


1,620,000 


1 0 


2 3 


•15 


T C.f\0 OOO 
x , j yjjCyKjyj^J 

I ,448,000 


1 1 


a=; 


I c c 

J J 


1 2 




1 38 


1 , 260,000 


1 1 


XO 


1. 20 


1, 250,000 




20 


.80 


1.237 ZOO 


T C 
L J 


18 


• J j 


1, 230,000 


l6 


JJ 


1.48 


T tSo OOO 

X , I OU.UV/U 


I 7 


26 


I 17 

X . X / 


1, 100,000 


l8 


IA 


67 


1 ,040,000 


19 


20 


1. 00 


1,000,000 
980,000 


20 


31 


1.58 


2 1 


l8 


1 .02 


875,000 


22 


20 


1. 19 


840,000 


23 


30 


1.87 


800,000 


24 


22 


1.38 


795,000 


25 


25 


1.60 


780,000 


26 


15 


•97 


768,000 


27 


20 


1.42 


700,000 


28 


12 


.96 


622,000 


29 


15 


1.20 


620,000 


30 


20 


i-75 


570,000 


31 


20 


1. 81 


550,000 


Average : 


25 + 


1.08 


1,343,6774- 



striking may be this feature of the blood-picture that it is some- 
times difficult to find any two cells in the same field of the micro- 
scope which are of the same diameter. In the great majority of 
cases it will be found that the megalocytes distinctly outnumber 
the microcytes, to such an extent and in such a large proportion 
of cases that some writers consider this change an almost con- 
stant blood finding in this disease. Large erythrocytes, measur- 
ing slightly below or above 10 // in diameter, are very common, 
while those measuring in the neighborhood of 15/^ or even 20 fi 
are met with more rarely. Undersized erythrocytes, about 3 or 
4 jut in diameter, are also numerous, but, as remarked above, 
much less so than those of larger size. The presence of small, 
dark-colored, spherical microcytes of this size (the so-called 



CHART L 



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PERNICIOUS ANEMIA. 
Red, Hemoglobin. Black, Erythrocytes. Blue, Leucocytes. 



PERNICIOUS ANEMIA. 



223 



"Eichhorst's corpuscles"), once regarded as pathognomonic of 
pernicious anemia, is neither constant nor diagnostic of this dis- 
ease, since they are found in many other anemic conditions, and 
are absent in a large proportion of cases of true pernicious anemia. 
The fact that, of these alterations in the size of the erythrocytes, 
megalocytosis predominates, constitutes a sign of valuable diag- 
nostic significance in this disease. 

Poikilocytosis , to a more or less marked degree, is constantly 
observed, the conspicuousness of the deformities being in some 
cases extreme, while in others the change is a less notable feature. 
While marked poikilocytosis usually goes hand in hand with 
excessive diminution in the number of erythrocytes and in the 
amount of hemoglobin, the association of these three changes 
cannot be invariably counted upon, for in some cases, in spite of 
the fact that both oligocythemia and oligochromemia are marked, 
deformities in the shape of the corpuscles are but trifling. All 
varieties of erythrocytes, small, large, nucleated, and non-nu- 
cleated, may be deformed, so that the size of the poikilocytes 
varies from that of the smallest microcyte to that of the largest 
megalocyte. The kinds of deformity are of infinite variety, but 
it is still possible to designate certain well-defined forms which 
are especially common in this disease, these being the horseshoe 
form (Litten), and the oval form (Cabot), both of which varieties, 
while by no means peculiar to this condition, are found so fre- 
quently and in such abundance in pernicious anemia that their 
presence in the blood is at least highly suggestive. Of these 
two forms, the elongated, oval erythrocyte is found more con- 
stantly, and has been described in but a few other conditions. 
The author has been struck with the predominance of cells of 
this sort in three consecutive cases of purpura hemorrhagica, 
in one of which the deformity was so marked that scarcely a 
single normally shaped erythrocyte could be found in certain 
fields of the microscope. Cabot 1 cites Greene as noticing the 
same change in the blood of two patients in whom the tentative 
diagnosis of epidemic dropsy had been made. In addition to 
these well-defined varieties, many cells of other shapes, also met 
with in other severe anemias, are observed, notably those resemb- 
ling the form of a sausage, or a spindle, or a club. (See Fig. 
38, page 221.) 

In the stained specimen the principal point of interest is the 
presence of nucleated erythrocytes, upon the character of which 
the diagnosis of pernicious anemia must depend. Erythroblasts 
are always to be found in this disease, at some stage of its course. 

1 Loc. cit. 



DISEASES OF THE BLOOD. 



Megaloblasts are of much greater clinical significance than nor- 
moblasts, and by a differential count will be found always to out- 
number the latter in eveiy genuine case of pernicious anemia, at 
some stage of the disease. This blood-picture, which indicates 
a megaloblastic degeneration of the bone marrow, due in all proba- 
bility to the influence of some unknown but specific toxic agency, 
is associated with only two other conditions, namely, nitrobenzole 
poisoning, and some cases of high-grade anemia due to bothri- 
ocephalus latus infection. The predominance of megaloblasts 
over normoblasts in pernicious anemia is well illustrated by Table 
IV., which shows that at the first examination the former type of 

Table IV. 



Approximate Number of Nucleated Erythrocytes per cb. mm. in 
Pernicious Anemia, at the First Examination. 



Number. 


Total. 


Megaloblasts. 


Normoblasts. 


Microblasts. 


I 


924 


6 93 


2IO 


21 


2 


840 


616 


I40 


84 


3 




C T2 

D 


l6 


l6 


4 


470 


320 


I50 


O 


5 


368 


207 


46 


115 


6 


336 


24O 


90 


6 


7 


328 


O 


328 


0 


8 


260 


20 


24O 


0 


9 


256 


144 


80 


32 


IO 


250 


l80 


70 


0 


ii 


235 


175 


60 


0 


12 


224 


168 


56 


0 


13 


204 


I48 


56 


0 


14 


200 


l60 


40 


0 


15 


192 


l80 


12 


0 


16 


I60 


96 


64 


0 


17 


IOI 


80 


21 


0 


18 


100 


O 


IOO 


0 


19 


96 


73 


23 


0 


20 


67 


47 


13 


7 


21 


60 


40 


20 


0 


22 


48 


32 


16 


0 


23 


48 


37 


7 


4 


24 


32 


24 


8 


0 


25 


20 


20 


0 


0 


26 


15 


15 


0 


0 


27 


10 


8 


0 


2 


28 


6 


6 


0 


0 


29 


3 


3 


0 


0 


Average : 


220-f- 


146+ 


64+ 


10 



cells outnumbered the latter in 26 out of the 29 cases here 
grouped together. The average proportion of megaloblasts to 
normoblasts in this series is somewhat more than 2 to 1, and in 



PERNICIOUS ANEMIA. 



225 



some cases the former were the only kind of erythroblast dis- 
covered. The total number of erythroblasts of all varieties aver- 
aged 220 per cubic millimeter of blood, ranging from as low as 
3 to as high as 924. Regarding this last statement, it should be 
remembered that it is not the actual number of nucleated erythro- 
cytes, but their character, which is all important in the diagnosis 
of this disease. 

Microblasts are rare in comparison to the other forms of nu- 
cleated erythrocytes ; in some cases they may be relatively nu- 
merous, but in the majority they are absent. They were noted 
in but 9 of the 29 cases tabulated above (Table IV.), their average 
number for the series being 10 to the cubic millimeter. In the 
differential count of nucleated erythrocytes, microblasts should 
be totalled with normoblasts, of which they are simply degenerate 
forms, more or less stripped of their protoplasm, and hence irreg- 
ular and ragged in outline. 

In addition to the foregoing types of erythroblasts, cells pos- 
sessing the characteristics of both the normoblast and the meg- 
aloblast may be observed in many instances. These atypical 
forms, and their clinical significance, have been described in a 
previous section. (See page 144.) In certain corpuscles, both 
of the normoblastic and megaloblastic types, division of the nu- 
cleus into several parts may have occurred, and in rare instances 
evidences of true karyokinesis may be seen. Normoblasts show- 
ing complete or partial nuclear extrusion and separation of the 
nucleus into a clover-leaf design are not uncommon, although 
pictures of this sort are found much more frequently in leukemia. 
In many cases of pernicious anemia one cannot but be struck 
with the fact that the majority of these atypical forms appear as 
cells with a megaloblastic protoplasm and a normoblastic nucleus ; 
they are, in the author's experience, much more numerous in this 
disease than cells having a normoblastic protoplasm and a meg- 
aloblastic nucleus, the latter being more common in leukemia. 

Fluctuations in the total number of erythroblasts occur from 
time to time during the progress of the disease, these changes 
sometimes taking place with great abruptness, being of wide 
range and often carrying not the slightest clinical import. A 
marked increase usually but not invariably precedes and accom- 
panies a gain in the number of erythrocytes and in the percentage 
of hemoglobin ; and a similar increase, usually associated with 
extreme diminution in the erythrocyte count, is commonly met 
with as a pre-agonal sign. 

Marked evidences of polychromatophilia are found in many of 
the erythrocytes, both of the nucleated and the non-nucleated 
15 



226 



DISEASES OF THE BLOOD. 



varieties. Such cells, when stained with Ehrlich's triacid mix- 
ture, instead of taking the normal orange color of the solution, 
stain some bastard tint, such as slate color, or dull purple, or 
dirty gray. Others may show a peculiar, streaked appearance, 
and irregular pale-white unstained areas, while others are scarcely 

Table V. 



Number of Leucocytes per cb. mm. and Percentage of Various Forms in 
Pernicious Anemia, at the First Examination. 31 Cases. 









Percentages of Different Forms. 




No. 


Leucocytes per 






















cb. mm. 


Small lym- 
phocytes. 


Large lym- 
phocytes. 


Polynuclear 
neutrophiles. 


Eosinophiles. 


Myelocytes. 


I 


13,000 


43-2 


2.8 


49.6 


2.8 


T A 

1 . 0 


2 


8, 200 


7-7 


2.0 


86.2 


1.6 


2-5 


3 


7,000 


14. 4 


1.6 


81.6 


2.0 


0.4 


4 


7,000 


13.0 


5-2 


77.6 


2.8 


r» Si 
O.o 


5 


6,400 


34-° 


4.0 


60.0 


1.0 


I .O 


0 


6,000 


1 1.0 


2.0 


84.0 


1.0 


2.0 


7 


5, OOO 


14.0 


3-o 


73-o 


0.0 


IO. O 


Q 
O 




22. 1 


7 5 


67.4 


2.0 


I.O 


9 


5,000 


10 5? 
32.5 


3-6 


55-6 




2.8 


10 


4, 600 


5 D -5 


6 n 


34-5 


00 


3° 


11 


4,100 


53-° 


6.4 


39-6 


0.0 


1.0 


12 


4,000 


30.0 


14-5 


52*4 


2.0 


1.1 


l 3 


4,000 


20.5 


15-5 


56.8 


0.9 


0.0 


14 


4,000 


23.0 


16.6 


58.2 


1.2 


1.0 


15 


4,000 


15.0 


5-o 


77-5 


0.5 


2.0 


16 


4,000 


34- 0 


9.0 


45-o 


8.0 


4.0 


17 


4,000 


16.3 


8.1 


72.6 


2.0 


1.0 


18 


3,100 


19.7 


23.0 


54-o 


1.0 


2-3 


19 


3,000 


10.8 


20.0 


60.0 


7.2 


2.0 


20 


2,500 


45-o 


12.0 


40.0 


1.0 


2.0 


21 


2,300 


22.1 


I6.I 


60.8 


0.0 


1.0 


22 


2,100 


32.1 


2I.3 


40.7 


1.6 


4-3 


23 


2,080 


45° 


14.7 


38.3 


1.0 


1.0 


24 


2,000 


65.0 


20.0 


14. 1 


0.0 


0.9 


25 


2,000 


14-5 


14.5 


69- S 


1.0 


0.5 


26 


I ,5°° 


25.0 


I4.O 


61.0 


0.0 


0.0 


27 


1,100 


19. 1 


12. 1 


67.7 


0.3 


0.8 


28 


1,000 


17.0 


2I.O 


58.0 


2.0 


2.0 


29 


1,000 


13.0 


TI.O 


72.0 


1.0 


3-o 


30 


1,000 


20.0 


9.O 


70.0 


0.5 


o-5 


31 


500 


37-5 


18.5 


40.8 


2.3 


0.9 


Av. 


3,925+ 


264- 


IO+ 


58+ 


1+ 


1+ 



stained at all, the greater part of the protoplasm remaining an 
indefinite shade of dead white. Granulai' degeneration of the 
protoplasm is distinctly evidenced in some of the cells, this proc- 
ess being betrayed by the appearance through the stroma of the 
affected cells of granular areas showing a striking affinity for a 
basic stain such as methylene-blue. These basophilic granules^ 



PERNICIOUS ANEMIA. 



227 



which have already been described, are not peculiar to pernicious 
anemia, since they have been found in a large number of secondary 
anemias of severe type, due to various causes. (See page 145.) 

Leucopenia may be counted on in about three 
Leucocytes, out of every four cases of pernicious anemia, a fact 
which stands in direct contrast to the anemias of 
secondary type, in which an increase in the number of leucocytes 
is more common. In an occasional case, especially in one in 
which the other blood changes are inconspicuous, the number of 
leucocytes is found to be normal ; and, rarely, a moderate leu- 
cocytosis, attributable to some complication, exists. In the aver- 
age case, however, these cells are distinctly below the normal 
standard, and the degree of leucopenia is sometimes extreme, 
the number of cells occasionally falling to below 1,000 to the 
cubic millimeter ; in rare instances, they may apparently be 
entirely absent, none being found after prolonged search both 
through the counting chamber and the stained film. In the 3 1 
cases collected in Table V., the number of leucocytes averaged 
about 50 per cent, of the normal count (3,925 being the exact 
figure), and ranged, in the individual case, from 500 to as high as 
13,000 to the cubic millimeter. It is interesting to note, in con- 
nection with the preceding remarks, that leucopenia was found in 
22, or about 70 per cent, of these cases. 

The leucocyte count, except in the event of complications, 
roughly parallels that of the erythrocytes, falling coincidently with 
the oligocythemia and rising again as the erythrocytes increase. 
(See Chart, p. 222.) An exception to this general rule is found in 
the terminal leucocytosis which not uncommonly develops just 
before the death of the patient. 

Relative lymphocytosis is a common, but not a constant, find- 
ing in the differential count of the stained film. It seems to be 
more frequently associated with low than with high counts, 
although no hard and fast rule can be laid down regarding this 
point. In extremely leucopenic blood a noteworthy finding is 
the abnormally high percentage of large mononuclear non-gran- 
ular cells, a change which does not ordinarily take place in con- 
nection with leucocyte counts approaching the normal average. 
The combined percentage of both large and small forms of lym- 
phocytes in the cases alluded to above (Table V.) averaged 37.8, 
individual counts varying from 9.7 to 85 per cent. Pre-agonal 
rises in the leucocyte count are sometimes lymphocytic in char- 
acter, resembling the blood changes seen in lymphatic leukemia, 
and sometimes purely polynuclear in type. The relative percent- 
age of polynuclear neutrophiles averages low (58.6 per cent, in the 



228 



DISEASES OF THE BLOOD. 



above series), but isolated counts show a considerable range ; 
their relative proportion to the other forms of leucocytes is largely 
determined by the fluctuations in the percentage of lymphocytes. 
The eosinophiles are almost invariably decreased, and not infre- 
quently they are wholly wanting, a circumstance which was made 
note of in more than 1 8 per cent, of the cases in the present series, 
in which the average percentage of these cells was 1.68. In an 
occasional case their percentage is above normal, as in cases 9, 16, 
and 19 in Table V. 

In no other disease save the spleno-medullary form of leukemia 
are myelocytes so constantly found, but almost always in relatively 
small percentages. In the cases under consideration these cells 
were absent in only two instances, the average figure for the 3 1 
cases being 1.82 per cent. In a single case (number 7) the re- 
markably high estimate (for this disease) of 10 per cent, of myelo- 
cytes was made, for in the other cases in which myelocytes 
occurred their percentage ranged from 0.4 to 4.3. 

In the stained specimen it is common to find that the leuco- 
cytes, particularly the polynuclear neutrophiles, are of smaller 
size and more deeply stained than they appear in normal blood. 
This peculiarity seems to be more constant and more striking in 
pernicious anemia than in any other disease, so far as the author 
has been able to determine. 

The number of blood plaques is exceedingly 
Blood variable, so that it is impossible to make definite 
Plaques. statements regarding either the increase or de- 
crease of these bodies. In some cases they ap- 
parently are greatly increased, as evidenced by the groups of 
agglutinated masses of these cells which are sometimes seen 
(von Limbeck 1 ), but in other cases it is evident that their number 
is appreciably diminished (Hayem 2 ). Van Emden 3 supports the 
latter view. In one case this observer estimated their number at 
between 32,000 and 64,000 per cubic millimeter. 

In a typical case of pernicious anemia the 
Diagnosis, blood-picture upon which the diagnosis rests is 
as follows : 

Hemoglobin. Marked absolute decrease, but of relatively higher 
percentage in many cases than the percentage of 
erythrocytes, this giving rise to a high color index. 

Erythrocytes. Striking decrease, commonly to 1,000,000 or less 
per cubic millimeter. Counts of about 500,000 

1 Loc. cit. 

2 " Lecons sur les Maladies du Sang," Paris, 1900. 
3"Bijd. t. d. ken. v. h. bloed," Leiden, 1896. 



PERNICIOUS ANEMIA. 



229 



are not uncommon during the later stages of the 
disease. 

Erythroblasts constant, cells of the megaloblastic 
type predominating. 

Megalocytes and microcytes, the former prevailing. 
Poikilocytes, usually numerous and conspicuous. 
Polychromatophilia. 

Basophilic stroma degeneration striking in severe 
cases. 

Leucocytes. Usually decreased ; decided leucopenia common. 

Relative lymphocytosis in the majority of cases. 
Small numbers of myelocytes almost invariably 
present. 

Eosinophiles few, sometimes absent. 
Plaques. Variable. 

Usually the diagnosis of pernicious anemia presents no difficul- 
ties, and may be made by the examination of the blood alone, 
the association of marked oligocythemia, a high color index, leu- 
copenia, and erythroblasts, chiefly of the megaloblastic variety, 
constituting a typical group of blood changes the significance of 
which is unmistakable. 

It should be borne in mind, however, that these changes are 
not always present in eveiy case when the patient first comes 
under observation, so that repeated and careful examinations of 
the blood are sometimes necessary before a diagnosis is possible. 
Of the above-named changes the most important, from a clinical 
viewpoint, is the prevalence of nucleated erythrocytes conforming 
to the megaloblastic type. With the two exceptions already noted 
(bothriocephalus anemia and nitrobenzol poisoning), this 4 'mega- 
loblastic blood-picture " is seen only in pernicious anemia, and, 
what is more important, it occurs in every true case of this dis- 
ease sooner or later during its course. Inability to detect this 
important characteristic should be regarded rather as a reflection 
upon the thoroughness of the examiner's technique than as a 
contradiction of the truth of this statement. Erythroblasts are 
not always numerous in pernicious anemia, and painstaking and 
prolonged study of several stained films may be necessary before 
this important feature is distinguishable. 

In those cases of doubtful nature, in which the typical blood 
changes are not at once evident, a tentative diagnosis may be 
made by taking into careful consideration certain other physical 
signs and symptoms which the patient presents. In such in- 
stances attention should be directed to such suspicious points in 



230 



DISEASES OF THE BLOOD. 



the clinical history as the existence of a severe anemia arising 
either idiopathically or without adequate cause, and pursuing a 
progressively unfavorable course, uninfluenced permanently by 
treatment ; the presence of a light lemon-yellow tint of the skin, 
of retinal hemorrhages, of a peculiarly soft, smooth, flabby condi- 
tion of the skin, and sometimes of moderate febrile paroxysms 
and gastric disturbances ; and the remarkable preservation of the 
patient's general nutrition and body-weight in comparison with 
the severity of the illness. 

The severe secondary anemias due to hemorrhage, to advanced 
syphilis, and to malignant disease, especially of the stomach, 
sometimes give rise to clinical symptoms which so exactly simu- 
late pernicious anemia that the diagnosis must rest upon the re- 
sult of the blood findings, which are usually well enough marked 
to differentiate the conditions. It is true that in these conditions 
ample proof of sufficient etiological factors for the production of 
the anemia is generally at hand, and this fact should have im- 
portant bearing in ruling out anemia of the pernicious type, but 
it is also equally true that in malignant disease it is sometimes 
impossible to demonstrate the lesion, and that in syphilis the 
clinical history may be obscure, so that the blood examination 
must, after all, often be depended upon for the detection of the 
disease. In secondary anemia from the above causes the oligo- 
cythemia is seldom as excessive as it is in pernicious anemia, the 
eiythrocytes rarely falling as low as 1,000,000 per cubic milli- 
meter ; the oligochromemia is apt to be relatively greater than 
the oligocythemia, so that a lower color index results ; leucocy- 
tosis is not uncommon ; and while deformities of shape and size 
and nucleation of the erythrocytes are frequently present, in 
some instances to as great an extent as in pernicious anemia, 
megalocytes do not predominate, nor do megaloblasts ever out- 
number normoblasts. 

From chlorosis, which sometimes possesses many clinical mani- 
festations in common with pernicious anemia, the diagnosis may 
usually be readily made by the blood examination, which shows 
decided differences between the two diseases. In a typical case 
of chlorosis the deterioration in the quality of the blood affects 
chiefly the hemoglobin content of the erythrocytes and not the 
cells themselves. Hence it is common to find in this disease 
extreme oligochromemia out of all comparison with the more 
moderate oligocythemia, and consequently a low color index — just 
the reverse of the condition found in pernicious anemia. De- 
formities in the shape and size of the erythrocytes are not un- 
common in chlorosis, but they are not likely to be conspicuous ; 



SPLENIC AMEMIA. 



2 3 I 



the prevalent change affecting their shape is microcytosis of a 
moderate grade of development, so that a general decrease in the 
diameter of these cells is commonly observed. The most im- 
portant information derived from the blood is, however, of a 
negative character, consisting in the fact that nucleated erythro- 
cytes, should they be present, are chiefly normoblasts. While 
it is true than an occasional megaloblast may be encountered in 
rare instances, no chlorotic blood has ever been known to show 
a predominance of this type of cells. The behavior of the leuco- 
cytes in chlorosis is of no aid in the differentiation of this condi- 
tion from pernicious anemia, for in both diseases the count is 
usually low and relative lymphocytosis common ; in the former, 
however, the pronounced leucopenia of the latter condition is not 
often found. Myelocytes, while they may occur in both diseases, 
are much less common in chlorosis. 

In bothriocephalus anemia the expulsion of the parasite by the ad- 
ministration of an appropriate vermifuge is soon followed by a radical 
change in the blood-picture and other symptoms, the megaloblasts 
disappearing, the hemoglobin and erythrocytes quickly rising to 
the normal standard, and the patient's health becoming entirely 
restored. The history of a patient suffering from anemia due to 
nitrobenzol poiso?iing is sufficiently characteristic to exclude true 
pernicious anemia. The differential diagnosis between this disease 
and splenic anemia is alluded to in another place. (See page 23 5.) 

III. SPLENIC ANEMIA. 

There is nothing distinctive about the appear- 
Appearance ance of the drop of freshly drawn blood, the 
of the color and density of which varies with the inten- 
Fresh Blood, sity of the anemia present. The author has 
notes of a case of splenic anemia in which it was 
remarked that, from its color and general appearance, the blood 
drop resembled precisely that obtained from a typical case of 
high-grade pernicious anemia ; in a second case the color and 
opacity were but slightly less than normal. 

No reliable observations have thus far been made regarding 
such minor points as the rate of coagulation, the specific gravity, 
and the reaction of the blood in this form of anemia. 

Decided often extreme anemia, is the general 
Hemoglobin rule in this disease. In the early stages, the 
and hemoglobin loss is relatively excessive as com- 
Erythrocytes. pared to the decrease in erythrocytes, so that the 
color index is consequently low — usually ap- 
proximating the figures found in many cases of high-grade sec- 



232 



DISEASES OF THE BLOOD. 



ondary anemia, but not averaging so low as in chlorosis. As the 
disease increases in severity, however, the color index tends to 
rise, as in pernicious anemia, this change being illustrated by the 
counts tabulated below. 

In a series of 14 cases lately reported by Osier, 1 the following 
results were obtained : the hemoglobin in 11 cases averaged 
43.7 per cent, the lowest estimate being 23 and the highest 60 
per cent.'; the erythrocytes in 10 cases averaged 3,336,357 per 
cubic millimeter, with extremes of 2,000,000 and 4,788,000. In 
a case of splenic anemia in Professor Hare's ward at the Jefferson 
Hospital the writer found the following changes, in five consecu- 
tive counts : 





Date. 


Hemoglobin. 


Color Index. 


Erythrocytes per 


3" 


" 7-98. 


45 per cent. 


.82 


2,750,000 


3" 


-14-98. 


40 - 


i i 


• 73 


2,725,000 


3- 


-22-98. 


43 " 


( ( 


.76 


2,8l2,000 


3- 


-29-98. 


45 " 


( ( 


.69 


3,275,000 


4- 


-II-98. 


40 " 


( 1 


I. OO 


2,000,000 



Deformities affecting the size of the erythrocytes, sometimes 
tending toward striking megalocytosis, may be met with in cases 
characterized by great oligocythemia, such an alteration being also 
associated with a greater or less degree of poikilocytosis, and with 
signs of stroma degeneration. Nucleated erythrocytes, although 
they occur infrequently, may be present in enormous numbers in 
severe cases, creating a blood-picture which is distinguishable 
from that of true pernicious anemia only by the fact that normo- 
blasts predominate. Thus, in one of McCrae's counts in a case 
of Osier's, in which the hemoglobin was reduced to 20 and the 
erythrocytes to 27.6 per cent., no fewer than 75 erythroblasts 
(of which 21 were normoblasts, 19 megaloblasts, and 35 " inter- 
mediate " forms) were seen while counting 400 leucocytes. In 
the case above summarized the average number of erythroblasts 
per 1,000 leucocytes was estimated as 67 (the maximum and 
minimum being 128 and 9, respectively) for the five examinations, 
41 of these cells being normoblasts, and 26 megaloblasts. The 
presence of nucleated erythrocytes in such large numbers as were 
found in these two instances must, however, be regarded as most 
exceptional. Polychromatophilic staining of many of the erythro- 
cytes may be a striking feature in advanced cases, but in those of 
a milder grade the phenomenon is absent. Absence of basophilic 
granular degeneration of the cells has been noted by Cohn. 2 

1 Am. Journ. of Med. Sc., 1900, vol. cxix., p. 54. 
2 Munch, med. Woch., 1900, vol. xlvii.,p. 618. 



SPLENIC ANEMIA. 



233 



Leucopenia, sometimes pronounced, is found in 
Leucocytes, the great majority of cases, counts of from 2,000 
to 4,000 cells to the cubic millimeter being com- 
mon ; as in pernicious anemia, the lowest leucocyte counts are 
generally associated with those cases in which the anemia is most 
intense. Leucocytosis occurs only as the effect of some compli- 
cation, and therefore is but occasionally encountered. In Osier's 
series, above referred to, the number of leucocytes, determined in 
13 cases, averaged 4,770 per cubic millimeter, ranging from 
2,000 to 12,497, the latter estimate being the only one exceeding 
10,000; in 9 of the cases the count fell below 5,000. In the 
writer's case the five counts averaged 2,400, varying from 1,000 
to 4,000. 

No constant differential changes have been observed, but rela- 
tive lymphocytosis is not infrequent, sometimes involving chiefly 
the large, and sometimes the small forms of these cells. The pro- 
portion of both combined may be as high as 50 or 60 per cent., 
an increase of this kind bringing about a consequent fall in the 
relative percentage of polynuclear neutrophiles. Small numbers 
of myelocytes, rarely in excess of a fraction of one per cent., 
are to be expected in cases with decided oligocythemia. The 
eosinophiles remain at about the normal standard. Typical 
coarsely-granular mast cells are sometimes found in relatively 
large numbers — as high as 5 or 6 per cent, of all forms of 
leucocytes. 

No special observations concerning the behavior of the blood 
plaques in this disease have been recorded up to the present time. 
It is evident, however, that they are not notably increased in 
number. 

To recapitulate, the blood changes which have 
Diagnosis, been most frequently found in splenic anemia 
may be tabulated as follows : 

Hemoglobin. Marked diminution ; color index variable. 

Erythrocytes. Usually reduced moderately, sometimes exces- 
sively. Counts between 3,000,000 and 4,000,000 
cells per cubic millimeter are most common. 
Deformities of shape, especially megalocytosis, and 
poikilocytosis common in advanced cases. 
Erythroblasts rare, except in cases with decided 
oligocythemia. Normoblasts invariably predomi- 
nate. 

Polychromatophilia in severe cases. 



234 



DISEASES OF THE BLOOD. 



Leucocytes. Leucopenia the general rule. 

Relative lymphocytosis common. 

Small numbers of myelocytes in advanced cases. 

Relatively large percentages of mast cells not 

uncommon. 

Eosinophiles normal. 

Plaques. Not increased. 

Many writers still hesitate to assign to splenic anemia the role 
of a definite clinical entity, choosing to regard the condition 
either as a splenic form of Hodgkin's disease, or as high-grade 
secondary anemia with marked splenic hyperplasia. But of late 
the majority of observers, especially those of the British school, 
lean toward at least a tentative recognition of the condition as a 
distinct although an obscure disease. 1 Osier 2 well expresses 
the consensus of opinion when he remarks that " provisionally, 
until we have further knowledge, it is useful to group together 
. . . cases of idiopathic enlargement of the spleen with anemia 
without lymphatic involvement, and to label the condition splenic 
anemia." 

It is quite obvious, from a glance at the above synopsis of the 
blood condition, that splenic anemia presents no characteristic 
blood-picture by which the diagnosis can be made, so that in 
order to differentiate it from a number of other diseases which it 
more or less closely simulates, careful study of other clinical 
features is essential. 

The onset of splenic anemia is gradual and insidious, its course 
is prolonged often for a number of years, and its termination is 
ultimately fatal. The principal clinical features are the leuco- 
penic anemia, the great splenic tumor, and the absence of all en- 
largement of the superficial lymphatics. In some instances the 
anemia develops in advance of the splenic tumor, but it is more 
often the case that the enlargement of the spleen is the earliest 
demonstrable lesion. The anemia is responsible for such symp- 
toms as dyspnea, vertigo, cardiac palpitation, loss of strength 
and appetite, and the occurrence of unexplained, irregular periods 
of fever ; and for such signs as hemic heart murmurs, pallor, 
lemon-yellow discoloration of the skin and mucous membranes, 
and sometimes pigmentation of the skin. The enlarged spleen 
may extend as far down as the umbilicus, and sometimes far be- 
low this point, even to the iliac crests ; the surface of the organ 

1 For a critical resume of the literature on splenic anemia, Sippy' s article in the 
American Journal of Medical Sciences, 1899, vol. cxviii., p. 570, should be consulted. 

2 Loc. cit. 



SPLENIC ANEMIA. 



235 



is smooth and free from nodules, its consistence is firm, and its 
shape is unaltered. It may give rise to no symptoms, but occa- 
sionally it is the cause of great pain and of hematemesis, the latter 
being due to simple mechanical congestion. Epistaxis, purpura, 
and hematuria have also been observed. Ascites sometimes de- 
velops, as the result either of the splenic enlargement, or of the 
anemia. Enlargement of the liver, usually associated with ca- 
tarrhal jaundice, occurs in a large proportion of cases, and such 
gastro-intestinal disturbances as anorexia, nausea, vomiting, and 
both constipation and diarrhea are extremely common. Splenic 
anemia may prove fatal within six months after the onset of the 
initial symptoms, or it may drag along for as many years, but, as 
a general rule, its duration does not exceed two or three years. 
In one of Osier's cases the condition probably lasted for at least 
twelve years, and in a case now under treatment in the Jefferson 
Hospital the splenic tumor and the anemia have existed for the 
last six years, if not longer. As in pernicious anemia, periods of 
remission during which the leading symptoms disappear and the 
quality of the blood improves, are commonly observed in this 
condition. 

The sple?io-medidlary form of leukemia, pernicious anemia, and 
Hodgkin 's disease with sple?iic enlargement all present clinical 
features counterfeiting more or less faithfully splenic anemia, but 
the differential diagnosis between these conditions does not in- 
volve any great difficulty. The result of the blood examination 
gives the clue to the two diseases first named, the myelocytic 
type of blood in leukemia, and the predominance of megaloblasts 
in pernicious anemia being sufficient to fix the identity of these 
conditions. In Hodgkin's disease with enlargement of the spleen 
there is more or less marked enlargement of the superficial 
lymphatic glands, and the splenic tumor rarely attains the size 
to which that organ grows in splenic anemia ; the blood-picture 
of the two conditions, it must be recalled, may be identical. 

Enlargements of the spleen due to such factors as chronic ma- 
larial infection, amyloid disease, malignant growths, echinococcus 
cysts, and hepatic cirrhosis also occasionally require differentiation 
from splenic anemia. A history of previous attacks of malarial 
fever, and the detection of the specific parasite or of pigment in 
the blood will serve to distinguish tumors of the spleen of malarial 
nature. In amyloid disease a histoiy of long-standing suppura- 
tion, of tuberculosis, or of syphilis, and the presence of signs in- 
dicating amyloid degeneration of other organs, notably the liver, 
kidneys, and intestines, are the chief differentiating features. In 
malignant disease of the spleen the tumor is uneven, irregular, 



236 



DISEASES OF THE BLOOD. 



and nodular, evidences elsewhere of malignant lesions generally 
exist, and a well-defined leucocytosis is common. Echino- 
coccus disease of the spleen pursues a protracted course unac- 
companied by signs of anemia, and, unless secondary infection 
takes place, unassociated with rises in temperature ; fluctuation of 
the tumor can frequently be detected ; and hooklets can be recog- 
nized in the fluid obtained from the organ by aspiration. In 
splenic enlargements associated with the different varieties of 
hepatic cirrhosis, the previous history and the cachexia of the 
patient, the relatively moderate size of the tumor, the signs of 
portal congestion, the condition of the liver, and the course of 
the disease should be taken into account. 



IV. SECONDARY ANEMIA. 

An approximate idea of the intensity of the 
Appearance anemia may usually be formed by noting the 
of the gross appearance of the fresh blood drop, but it 
Fresh Blood, must be remembered that it is only when the 
process has reached a comparatively high grade 
of development that the fact is betrayed by any marked devia- 
tion from normal in the color and density of the blood. In the 
average case of well-marked secondary anemia the color of the 
drop is but slightly paler than normal, if, indeed, it is visibly al- 
tered ; but if the anemia is of decided severity it may resemble a 
thin, serum-colored liquid streaked with crimson, similar to the 
watery blood drop of typical pernicious anemia. In such cases 
microscopical examination of the fresh film shows that there is 
little or no tendency toward rouleaux formation. 

In general terms, it may be stated that the 
Coagulation, rapidity of coagulation bears a direct relation 
to the grade of the anemia, since it has been 
determined that the greater the oligochromemia and oligocy- 
themia, the more rapid the process of clotting. In secondaiy 
anemias with erythrocyte counts under 1 ,000,000 Lenoble l - 
found that coagulation was, as a rule, at least twice as rapid as 
normal. 

The specific gravity of the whole blood is re- 
Specific duced, a change which is dependent chiefly upon 
Gravity. the loss of hemoglobin. Sufficient reference has 
already been made to this subject in a previous 
section. (See page 98.) 



1 Loc. cit. 



SECONDARY ANEMIA. 



237 



The majority of authors maintain that the al- 
Alkalinity. kalinity of the blood is decreased in relation to 
the degree of the anemia, and a large number of 
experiments in anemias due to various factors apparently justify 
this general belief. But several careful investigators, notable 
among whom is Lowy, 1 have contradicted these reports, having 
found the alkalinity normal or even above normal in numerous 
cases. The author quoted, for example, calculated the alkalinity 
in various cases of secondary anemia at from 360 to 675 mgrms., 
as compared with his normal standard, 447 to 508 mgrms. 

Taking the ordinarily well-developed case of 
Hemoglobin secondary anemia as an example, it is found that 
and the hemoglobin percentage and number of erythro- 
Erythrocytes. cytes are both decidedly, though not strikingly, 
diminished. As the former usually shows a dis- 
proportionately greater loss than the latter, subnormal color in- 
dices are the rule, ranging, say, from about 0.75 to 0.85. In 
anemias of severer type, such as those due to gastric cancer and 
to enteric fever, the losses frequently are much more exaggerated, 
and, in so far as the purely quantitative changes in the erythro- 
cytes and their hemoglobin equivalent are concerned, the blood 
picture of true pernicious anemia may be counterfeited. In the 
anemias of syphilis, of tuberculosis, and of malignant disease in 
general the disproportionate hemoglobin loss may be so decided 
that the blood changes cannot be distinguished from those of 
chlorosis, and to this condition the much-abused term " chloro- 
anemia " has been applied. 

The fact must be emphasized that simply the hemoglobin esti- 
mate and erythrocyte count alone are absolutely uncharacter- 
istic in secondary anemias, for they may range in the individual 
case from slightly subnormal figures to an extreme degree of 
oligochromemia and oligocythemia. In a patient studied by 
von Limbeck, 2 for example, at one time the eiythrocytes num- 
bered only 306,000 per cubic millimeter, but ultimately perfect 
recovery ensued and the count rose to 4,280,000. But if aver- 
ages are used as a basis for conclusions, it becomes evident that 
the hemoglobin diminution is less marked than in any other blood 
disease, and that the erythrocyte loss is also less than in any 
other form of anemia except chlorosis. Data based upon 200 
examinations of various types of anemia by the writer give the 
following results regarding these points : 

1 Centralbl. f. d. med. Wissensch., 1894, vol. xxxii., p. 785. 
2 Loc. cit. 



2 3 8 



DISEASES OF THE BLOOD. 



Disease. 


Average Percentage of Hemo- 
globin Loss in 50 Consecu- 
tive Estimates. 


Average Percentage of Ery- 
throcyte Loss in 50 Con- 
secutive Counts. 


Secondary Anemia. 


44.8 per cent. 


27.1 per cent. 


Chlorosis. 


54-8 " 


17.8 


Leukemia. 


60.6 " 


45-4 


Pernicious Anemia. 


74-5 " 


76.9 



Examination of the stained specimen shows a variable degree 
of alteration in the shape, size, and general structure of the cells. 
In mild cases simple pallor of the erythrocytes, with perhaps a 
few microcytes and moderately misshapen poikilocytes are the 
only changes to be observed, erythroblasts, polychromatophiles, 
and cells with basophilic stroma degeneration being entirely 
wanting. In severe cases, with excessive oligocythemia, a large 
proportion of the cells are either under- or over-sized, the latter 
forms appearing to prevail in relation to the intensity of the ane- 
mic process ; poikilocytosis and polychromatophilia are sometimes 
extreme, and evidences of Grawitz's stroma degeneration are 
found, together with a more or less abundance of nucleated eryth- 
rocytes, the majority of which conform to the normoblastic 
type. In most instances normoblasts only are present, but rarely 
an occasional megaloblast, implying a slight tendency toward a 
fetal type of hemogenesis, is also seen. The significance of 
erythroblasts in anemia and the circumstances under which they 
are found have been discussed in a preceding section. (See page 
141.) 

Typical polynuclear neutrophile leucocytosis 
Leucocytes, is common but by no means constant in the sec- 
ondary anemias, independent of their grade, for 
the cellular increase is provoked by a stimulation of the functional 
activities of the marrow, which vary according to the individual 
and to the nature of the exciting cause. The differential changes 
associated with such a leucocytosis (low percentages of lympho- 
cytes and eosinophiles, with, perhaps, a few myelocytes) have 
already been referred to in a preceding section. A moderate 
leucocytosis is especially common in the anemias of children, 
and in those symptomatic of inflammatory and suppurative condi- 
tions and of malignant diseases. While in other anemias, espe- 
cially those of chronic type, a normal leucocyte count or even 
leucopenia may be found, often in association with a relative 
lymphocytosis, as is frequently the case in the anemias of enteric 
fever and of tertiary syphilis. 



POST-HEMORRHAGIC ANEMIA. 



239 



The plaques are usually increased, but appa- 
Blood rently without any constant relationship to the 
Plaques. degree of hemoglobin and erythrocyte loss. In 
some cases these bodies may number more than 
double the maximum normal standard, as in a case of anemia in 
a child with a tumor of the spleen, noted by von Emden, 1 in which 
an estimate of 829,000 to the cubic millimeter was made. 

The principal blood changes found in second- 

DlAGNOSIS. r . r r u 

ary anemia are as follows : 

Hemoglobin. Variable decrease, usually somewhat more marked 
than the erythrocyte loss ; color index subnormal. 

Erythrocytes. Variable decrease. 

Erythroblasts, in severe cases; normoblasts out- 
numbering megaloblasts, which are rare. 
Deformities of shape and size, polychromatophilia, 
and basic staining of the stroma in severe cases. 

Leucocytes. Commonly increased ; rarely leucopenia. 

Polynuclear neutrophiles usually increased, and 
lymphocytes and eosinophiles relatively dimin- 
ished. 

Lymphocytosis in some cases, usually those of 

severe type and chronic course. 

Small numbers of myelocytes sometimes found. 



Plaques. 



Usually increased. 



V. POST-HEMORRHAGIC ANEMIA. 

Among the many underlying causes of acute 
Etiology, post-hemorrhagic anemias may be mentioned 
trauma, abortion, postpartum hemorrhage, epis- 
taxis, pulmonary tuberculosis, peptic ulcer, enteric fever, visceral 
carcinoma, hemorrhagic pancreatitis, and the rupture of an aneu- 
rysm, of a Fallopian tube during ectopic pregnancy, and of a mass 
of extensively varicose veins. Chronic hemorrhages resulting, 
for example, from diseases belonging to the hemorrhagic diathesis, 
from hemorrhoids, or from uterine diseases usually give rise to a 
much less decided blood loss than the first-named conditions, but 
in some instances these factors, if persistent, may be sufficient to 
provoke eventually a high-grade anemia. 



1 Loc. cit. 



240 



DISEASES OF THE BLOOD. 



Reduction in the total volume of blood, or 
Effect Upon oligemia, ensues as the immediate effect of an 
the Blood, acute hemorrhage, and a count made immedi- 
ately after the blood loss may show no reduction 
in the hemoglobin and corpuscular value, since the oligemia af- 
fects the liquid and cellular elements proportionately. As reac- 
tion sets in, the system attempts to compensate for the loss of 
blood, by the rapid absorption by the capillaries of large amounts 
of liquids from the tissues, so that the blood soon becomes highly 
diluted, or hydremic. This is evidenced by a proportionate dimi- 
nution in the hemoglobin percentage and erythrocyte count, the 
degree of this decrease depending upon the extent of the hem- 
orrhage. It is thought that in many instances this fluid transfer 
from tissue to vessel is inaugurated immediately after or even 
during the hemorrhage, and that the original volume of blood is 
restored within a few hours. A further diminution in hemo- 
globin and erythrocytes occurs after the normal volume of blood 
has been reestablished, so that the minimum decrease is not ob- 
served until some little time has elapsed after the hemorrhage. 
As a rule, the minimum count is seen at some period during the 
first week after the blood loss, as early as the first or second day 
in some instances, but as late as the tenth or eleventh day in 
others. This secondary fall is thought to depend upon the in- 
troduction into the circulation of large numbers of immature, 
feebly resistant erythrocytes, which suffer rapid and premature 
destruction, and thus bring about a disturbance in the equilibrium 
between the rate of blood production and blood destruction in 
favor of the latter. As soon as the marrow is able to meet the 
drain in an adequate manner, by the increased production of more 
resistant cells, the anemia ceases, and the hemoglobin and eryth- 
rocyte estimates begin to rise. 

Authorities differ as to the degree of blood loss which man is 
capable of surviving, a difference which is but natural when it is 
remembered that factors other than the actual amount of blood 
lost, conspicuous among which are the age, sex, and resisting 
powers of the patient, are all important in determining the fatality 
of the hemorrhage. According to Immermann, 1 hemorrhages 
involving a loss of one-half of the total bulk of blood in the 
body invariably prove fatal. Hayem 2 is authority for the state- 
ment that, as a general rule, recovery is possible when the total 
volume of blood lost does not exceed j^th of the individual's 
body-weight. This author has reported the most astonishing 

1 Cited by Rieder, loc. cit. 
2 Loc. cit. 



POST -HEMORRHAGIC ANEMIA. 



241 



example on record of post-hemorrhagic cellular decrease, in 
which he observed a diminution in the erythrocytes to 1 1 per 
cent, of normal, in a case of post-partum hemorrhage, with sub- 
sequent recover}' of the patient. Behier 1 has described a case 
of metrorrhagia in which recovery occurred, in spite of a reduc- 
tion in the erythrocytes to 19 per cent, of normal. Laache 2 has 
recorded a number of instances in which the corpuscular esti- 
mates fell below 50 per cent, of normal, in one case to 32 per cent. 
These last three examples are sufficient to disprove the former 
belief, that death inevitably ensues when the corpuscular loss, as 
the result of hemorrhage, falls as low as 50 per cent, of normal. 

Increase in the number of leucocytes, usually of moderate de- 
gree, promptly develops in the great majority of cases, and per- 
sists for several days. It usually involves an absolute and rela- 
tive gain in the polynuclear neutrophile cells with a consequent 
decrease in the mononuclear forms, but, rarely, the reverse may 
be noted. In fatal cases this increase may not occur. 

The maximum count is commonly attained within a few hours 
after the onset of the leucocytosis. (See " Post-hemorrhagic 
Leucocytosis,'* page 191.) 

According to most authors, the blood plaques are strikingly in- 
creased after hemorrhage. The coagulability of the blood is ab- 
normally quick, being more rapid in profuse than in moderate 
hemorrhages. 

Following the reestablishment of the normal 
Regexera- blood volume, regeneration of the erythrocytes 
tiox. and hemoglobin, and a consequent dissipation of 
the hydremia, ensues. The time necessary for 
the completion of this process varies greatly in different individ- 
uals, as the rapidity with which blood regeneration occurs depends 
upon different factors, such as the extent of the original hemor- 
rhage, and the age and natural regenerative powers of the patient. 
The latter are at their maximum during the third and fourth 
decades of life, at their minimum during infancy and old age, and 
are regarded as more active in women than in men. The exist- 
ence of a well developed cachexia, or an infectious disease, as 
well as the neglect of proper treatment of the hemorrhage, are 
obstacles which retard the regeneration of the blood to its normal 
composition. The process appears to be more active if trans- 
fusion of a normal saline solution has been practised than in un- 
treated cases, the rapidity of the gain being especially striking 
during the latter half of the regeneration period. The transfusion 

1 Cited by Laache, loc. cit. 

2 " Die Anemie," Christiania, 1888. 

16 



242 



DISEASES OF THE BLOOD. 



of blood hastens regeneration even more decidedly. Otto, 1 and 
Hall and Eubank 2 have shown experimentally in animals, bled 
and given transfusions of artificial serum, that regeneration once 
stimulated into activity may carry the blood, quantitatively, con- 
siderably beyond the established normal standard. 

In uncomplicated cases, according to Bierfreund, 3 regeneration is 
effected within about four weeks if the hemorrhage produces a hem- 
oglobin loss of 25 per cent., and in about three weeks if the loss 
does not exceed 20 percent. The latter period maybe regarded 
as the average regeneration time in the great majority of instances. 

As regeneration proceeds, the hemoglobin and corpuscular 
deficiencies gradually become less conspicuous, but the increase 
in these two constituents does not occur along parallel lines. 
The increase in the number of erythrocytes is much more rapid 
than the gain in the hemoglobin percentage, and the latter usually 
remains subnormal for some time after the normal number of 
corpuscles has been reestablished. Owing to this lagging behind 
of the hemoglobin, low color indices are the rule. Faulty 
hemogenesis, owing to which -the great majority of the erythro- 
cytes are deficient in hemoglobin and many of them of abnormally 
small size, serves best to explain this slow restitution of the hemo- 
globin value. 

The appearance in the blood of normoblasts is common after 
hemorrhage, and in rare instances an occasional megaloblast and 
atypical forms of erythroblasts may be observed. According to 
Ehrlich, 4 if thorough and systematic search is made, normoblasts 
may be constantly found after the second or third day following 
the blood loss until the regeneration of the blood is complete. 
The transient appearance of large numbers of normoblasts, known 
as " blood crises," has been already described. (See page 143.) 
Dawson, 5 who has carefully studied the effects of venous 
hemorrhage in dogs, found no evidence of any close relation 
between the number of erythroblasts and the rapidity and char- 
acter of the regeneration of the hemoglobin and erythrocytes. 
In severe cases polychromatophilia of the erythrocytes may be 
noted, this sign first becoming apparent as early as the first day 
after the hemorrhage, and gradually disappearing as regenera- 
tion is effected. Deformities in the size and shape of the erythro- 
cytes are not uncommon, of which microcytes constitute the most 
frequent example. Large hydropic macrocytes and poikilocytes 
are met with more rarely. 

1 Pfliiger's Archiv., 1885, vol. xxxv., p. 57. 

2 Journ. of Exp. Med., 1896, vol. i., p. 656. 

3 Langenbeck's Archiv., 1890-91, vol. xli., p. I. 
4 Loc. cit. 

5 Amer. Jour, of Physiol., 1900, vol. iv., p. 2. 



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244 



DISEASES OF THE BLOOD. 



VI. LEUKEMIA. 

According to the classification in general vogue 
Varieties. at the present time, two clinical varieties of leu- 
kemia, the spleno-medullary and the lymphatic, are 
recognized. The spleno-medullary variety, which is almost in- 
variably a chronic process, is associated with a marked prolifera- 
tion of myeloid tissue, and is characterized by a striking myelemia 
and generally by conspicuous enlargement of the spleen with little 
or no involvement of the lymphatic glands. The lymphatic form, 
which may run either an acute or a chronic course, more com- 
monly the latter, is a process associated with a proliferation of 
lymphoid tissue, and is characterized by a blood-picture known 
as lymphemia and in the great majority of cases by marked en- 
largement of the lymphatic glands with moderate involvement of 
the spleen. But these two clinical pictures, in so far as they relate 
to the splenic and lymphatic hypertrophy, are by no means con- 
stant, for, although cases of the spleno-medullary leukemia always 
have enlarged spleens, exceptionally they may also have decided 
lymphatic hyperplasia. Furthermore, cases of lymphatic leukemia 
are occasionally encountered in which there is a marked splenic 
tumor without demonstrable signs of lymphatic enlargement. 
Because of such atypical examples, the gross appearance of the 
spleen and lymphatics must be regarded as a sign of distinctly 
secondary importance to the blood-picture, which is alone the tan- 
gible diagnostic clue. 

Of the two forms of the disease, the spleno-medullary is much 
the commoner. In the series of 20 cases of leukemia which the 
writer has had the opportunity of studying, 1 2 were of the spleno- 
medullary, and 8 of the lymphatic form; while of Cabot's 41 
cases, 1 28 were spleno-medullary and 13 lymphatic — a proportion 
of about two of the former to one of the latter, for the combined 
series of 61 cases. 

In the present state of our knowledge, it is 
Parasitology, not possible to regard leukemia as a disease of in- 
fectious origin, notwithstanding the suggestive - 
ness of the symptoms shown by many of those cases which run 
an acute course. Within the past few years several investigators, 
notably Delbert, 2 Kelsch and Vaillard, 3 Pallowski, 4 and Lowit 5 
have attempted to ascribe to various micro-organisms specific 

1 Loc. cit. 

2 Bull. et mem. Soc. de chir., Paris, 1895, v °l- xx i-> P- 7^8. 
3 Annal. de l'lnstitut Pasteur, 1890, vol. iv., p. 276. 
4 Deut. med. Woch., 1892, vol. xviii., p. 641. 
5 " Die Leukamie als Protozoeninfektion," Wiesbaden, 1900. 



LEUKEMIA. 



245 



etiological relationship with the condition, but none of these at- 
tempts have thus far been convincing. L6 wit's researches, how- 
ever, are worthy of special attention, if for no other reason than 
the elaborate and painstaking study which they represent. This 
author believes that two distinct forms of parasites may be dem- 
onstrated in leukemia : the hemameba leukemia magna, thought 
to be the specific cause of the spleno- medullary form of the dis- 
ease, and the hemameba leukemic? parva, which he claims is the 
definite infective principle of the lymphatic form. These so-called 
" specific bodies," which are found both in the blood of the pe- 
ripheral vessels and in the hematopoietic organs, have either 
a granular or an ameboid appearance, and bear a more or less 
close resemblance to the basophile granules of the leucocytes ; 
navicular, segmenting, and vacuolated forms are also said to 
occur. They are either attached to, or lie within, the leucocytes, 
especially the small lymphocytes, and more rarely the other varie- 
ties of normal leucocytes and the myelocytes ; in an occasional 
instance they are said to be found lying free in the plasma. Al- 
though it is claimed that a leucocytic infection has been produced 
in animals by the injection of blood presumably containing these 
micro-organisms, all attempts to cultivate them on artificial media 
have proved futile. Lowit's amebae are demonstrable only in heat- 
fixed specimens, stained preferably with a steaming hot solution 
of L6 filer's methylene-blue, after which they are washed, differ- 
entiated with a 0.3 percent, solution of hydrochloric acid-alcohol, 
again washed, and mounted. In specimens thus treated they 
stain metachromatically, and, if the acid-alcohol differentiation 
has been properly effected, are the only elements except the 
basophile leucocyte granules which retain the color of the dye. 
Turk, 1 who has followed out Lowit's technique precisely, in in- 
vestigating this author's claims, has come to the conclusion that 
these " specific bodies " are in no sense of parasitic nature, but 
merely artefacts resulting from the action of an aqueous solution 
of a basic dye upon the mast cell granules, which causes the 
partial solution of the latter elements and deforms them. Turk 
claims, furthermore, that these so-called amebae can be produced 
both in the normal blood of man and in the blood of rabbits. 

1 XVIII. German Con. for Internal Med., Wiesbaden, Apr. 18-21, 1900. 



246 



DISEASES OF THE BLOOD. 



SPLENO-MEDULLARY LEUKEMIA. 

The drop as it flows from the puncture is, in 
Appearance most instances, of a bright scarlet color, and 
of the often has a peculiar and misleading appearance 
Fresh Blood, of density. After brief exposure to the air, it 
may split up into two portions, a serous, scarlet 
fluid, in which are suspended many minute, whitish, fat-like 
masses ; the former appears to consist of serum and erythro- 
cytes, and the latter of adhering masses of leucocytes. It was 
probably this striking appearance of the leukemic blood drop 
that led Hughes Bennett erroneously to describe the condition 
as a " suppuration of the blood" before he proposed the more 
suitable term leucocythemia. In some cases the drop is simply 
much darker than normal, but it is difficult to believe that it ever 
resembles the chocolate-brown shade mentioned by some authors 
as occurring in this disease. The blood usually flows veiy freely 
from the wound, often by fine jets and spurts, especially if slight 
pressure is applied above the site of the puncture. 

Microscopically, the field is found to contain an enormous 
number of leucocytes, the proportion of these cells to the ery- 
throcytes being, by actual count, as great as 1 to 8 or 6, or 
even greater. Many different varieties of leucocytes may be dis- 
tinguished in the fresh specimen, the most striking being the 
large, mononuclear, finely granular cells of round or ovoid shape. 
These are the myelocytes which are present in enormous num- 
bers in this form of leukemia, of which they form a characteristic 
blood-picture. " Fractured " leucocytes, usually eosinophiles, 
with a cloud of escaped granules free in the plasma in the neigh- 
borhood of the disrupted cell body, may also be observed in vari- 
able numbers, although such cells are more numerous in the 
dried, stained film. ( See Figs. 39 and 40.) 

The erythrocytes vary in number and in appearance according 
to the severity of the coexisting anemia ; in some instances large 
numbers of poikilocytes, megalocytes, and microcytes, with 
marked pallor of the corpuscles may be seen, while in others 
the changes affecting the erythrocytes appear to be but tri- 
fling. 

In fresh films which have been allowed to dry for some time 
Charcot-Leyden crystals may sometimes be detected. They ap- 
pear as colorless, refractive crystals, shaped like octahedrons, 
having long, pointed, sharp angles, and occurring either singly or 
in twos or threes, superimposed at right angles or as collections 
of radiating crystalline masses. These crystals are not observed 



PLATE IV. 



9 



15 



Spleno-Medullary Leukemia. 
( Triacid Stain.) 

1 . Small Lymphocyte. 

2. Large Lymphocyte. 

Contrast this cell with the myelocytes, io, it, and 12, noting the presence of neutro- 
phile granules in the latter, and their absence in the lymphocyte. The size and 
nuclear characteristics of all these cells are practically the same. 

3. 4. Polynuclear Neutrophiles. 

5. Eosinophile. 

In this "dwarf" eosinophile, ruptured during the preparation of the specimen, the 
granules are peculiarly arranged about the nucleus; no signs of protoplasm are dis- 
tinguishable. 

6. Eosinophilic Myelocyte. 

Note the irregularity with which the granules are stained. 

7. 8, 9, 10, 11, 12, 13, 14, 15. Myelocytes. {Neutrophilic.) 

These cells vary greatly in size (compare 8 with 9), but they all have similar distinc- 
tive characteristics — a large opalescent nucleus containing a scanty chromatin net- 
work embedded in a cell body crowded with delicate neutrophile granules, precisely 
like those found in the polynuclear neutrophiles, 3 and 4. The nucleus of 7 is dis- 
tinctly indented and somewhat denser than that of the other myelocytes. This cell 
probably represents a developmental phase of the myelocyte just short of its transi- 
tion into a typical polynuclear neutrophile. 
16. Normoblast. 

The erythrocytes (stained orange) show many evidences of deformity, an occasional 
megalocyte, many microcytes, and a few poikilocytes being present. Polychromato- 
philia is absent. 

(E. F. Faber, 



SPLENO-MEDULLARY LEUKEMIA. 



247 



in the freshly drawn blood, being demonstrable only in films 
which have stood exposed to the air for at least twenty-four 
hours, and only occasionally even under this circumstance. 

On account of the presence in the blood of such large numbers 
of leucocytes, a very small drop should be used for making the 
cover-glass spreads for staining, since it is advisable to avoid 
overcrowding the field with these cells. No difficulty will be ex- 
perienced in obtaining thin, evenly distributed spreads, if this pre- 
caution is observed, especially if the cover-glasses are slightly 
warmed just before they are used. 

The coagulation time of the blood and the for- 
Coagulation. mation of the fibrin network must be regarded as 

variable. In some cases, especially those with 
great loss of hemoglobin and erythrocytes, both processes are de- 
layed and imperfect, as evidenced by the formation of the " rasp- 
berry-jelly" clots referred to by the German writers. But in 
other cases the coagulation time is unaltered, and the fibrin net- 
work is perfectly normal. 

The alkalinity of the blood is usually decreased, 
Alkalinity, and, as in chlorosis, it increases after the patient 

is given iron, in parallelism with the gain in hem- 
oglobin and erythrocytes. In 3 cases studied by Burmin, 1 an 
average alkalinity equivalent to 0.146 grm. was found, Landois' 
method being employed in the investigations. Taylor 2 found an 
average of 0.380 grm. in three cases, tested by the von Limbeck 
method. 

In cases with severe anemia the density of the 
Specific blood may fall as low as 1035 or 1040. Gra- 
Gravity. witz 3 has reported a case in which the figure was 
1023. The fallacies in leukemia of Hammer- 
schlag's tables of specific gravities and their hemoglobin equiva- 
lents have already been pointed out. (See page 100.) 

Decided hemoglobin and erythrocyte loss is 
Hemoglobin the invariable rule sooner or later during the 
and course of the disease, the anemia usually being 
Erythrocytes, well defined at the time the patient first comes 
under observation, and becoming acutely marked 
as the termination of the illness approaches. It is generally the 
case that the hemoglobin loss is disproportionately greater than 
the decrease in the erythrocytes, thus producing a moderately 
low color index, but in some cases just the opposite of this is ob- 

1 Loc. cit. 
2 Loc. cit. 
3 Loc. cit. 



248 



DISEASES OF THE BLOOD. 



served. 1 In the writer's 12 cases, grouped in Table VI., the 
color index averaged about 0.9, being 1.00 or higher in one-third 
of the cases, and not falling below 0.50 in the remaining two-thirds, 
being usually above 0.65. The hemoglobin percentage ranged 
between 30 and 70, averaging 49 ; and the number of erythro- 
cytes was as low as 2,000,000 and as high as 4,000,000 per cubic 
millimeter, the mean average being about 2,800,000 ; the count 
of these cells was diminished to one-half of the normal standard, 
or below this figure, in exactly one-half of the cases examined. 
An analysis of Cabot's series of 28 cases of spleno-medullary 
leukemia 2 shows these average findings, which are not mate- 
rially different from those just given : hemoglobin, 52 per cent.; 
erythrocytes, 3,120,000 per cubic millimeter; and color index, 
about 0.6. 

Fluctuations in the hemoglobin percentage and the number of 
erythrocytes may or may not accompany variations in the leuco- 
cyte count. Sometimes, as the leucocytes rise, the erythrocytes 
fall, but again they remain practically stationary ; or, the leuco- 
cytes may progressively fall to a comparatively moderate count, 
coincidentally with an apparent improvement in the patient's gen- 
eral condition, and yet the erythrocytes do not materially gain in 
numbers. Taylor 3 refers to two such instances which have come 
under his observation, in both of which the blood-picture at cer- 
tain brief intervals resembled that of pernicious anemia, for under 
the influence of energetic arsenical treatment the leucocytes were 
reduced to normal, while the oligocythemia stubbornly persisted. 
In a case studied for a protracted period, it is possible to distin- 
guish a general decrease in the erythrocyte count as the leuco- 
cytes increase, although the reverse may not be true. (See Chart 
II., page 250.) 

Examination of the stained specimen shows the presence of 
nucleated erythrocytes in practically every case of spleno-medul- 
lary leukemia, these cells often being many times more numerous 
than in grave cases of pernicious anemia. Normoblasts prevail, 
always being more numerous than megaloblasts ; in some cases 
they are the only type of erythroblast to be observed ; in others 
they are associated with a relatively moderate number of typical 

1 It is to be remembered that hemoglobin estimates in leukemia may be unreliable 
(except when Dare's instrument is used), for correct readings are sometimes impos- 
sible, owing to the milkiness of the diluted blood from the presence of such immense 
numbers of leucocytes. Three-fourths of the hemoglobin figures in the accompany- 
ing table (Table VI.) were obtained by means of von Fleischl's hemometer, the 
remainder being based upon examinations with Oliver's instrument. 

2 Loc. cit. 
3 Loc. cit. 



SPLENO-MEDULLARY LEUKEMIA. 



249 



Table VI. 

Hemoglobin and Erythrocytes in Spleno-Medullary Leukemia, at the 
First Examination. 12 Cases. 



Number. 


Hemoglobin Percen- 
tage. 


Color Index. 


Erythrocytes per 
cb. mm. 


I 


70 


.87 


4,000,000 


2 


45 


•51 


3,973,000 


3 


68 


.90 


3,760,000 


4 


45 


.66 


3,400,000 


5 


40 


.65 


3,100,000 


6 


70 


i-37 


2,550,000 


7 


60 


1.30 


2,300,000 


8 


33 


.71 


2,300,000 


9 


40 


.87 


2,287,000 


10 


45 


1. 12 


2,l6o,000 


11 


40 


1. 00 


2,000,000 


12 


30 


•75 


2,000,000 


Average : 


49 


.89 


2,819,167 



megaloblasts, or, more commonly, with large numbers of atypical 
forms, sharing the characteristics of the typical adult and em- 
bryonic nucleated erythrocytes. In the 9 cases of this variety of 
leukemia in which the writer has made differential erythrocyte 
counts, the following estimates were obtained, at the first exami- 
nations : 



Total number of ery- 
throblasts per cb. mm. 



[2,913 
9,178 
8,626 
8,064 
5,694 
3,234 
2,940 
1,980 
748 

5,931 



Normoblasts per 
cb. mm. 



8,376 
9,178 
7,264 
6,048 
3,504 
1,848 
2,940 
1,980 
748 

4,654 



Megaloblasts per 
cb. mm. 



4,537 
o 

1,362 
2,016 
2,190 
1,386 
o 
o 
o 

1,277 



Comparison of the above summary with the table giving the 
number and forms of erythroblasts in pernicious anemia (Table 
IV., page 224) illustrates two striking facts concerning these 
cells in spleno-medullary leukemia : the immense numbers in 
which they occur, and the predominance of normoblasts over 
megaloblasts. Periods of temporary improvement in the pa- 
tient's general health are often heralded by a notable increase in 
the normoblasts, but it is a noteworthy fact that during these re- 



250 



DISEASES OF THE BLOOD. 



missions, while the leucocytes may fall decidedly, the normo- 
blasts tend to persist in greater or less numbers. 

Examples of so-called nuclear extrusion, of multinucleation, 
of clover-leaf, dumb-bell or other irregularly formed nuclei, and 
even, in rare instances, of karyokinesis are observed in many of the 
normoblasts. Such alterations may be more conspicuous in 
highly developed cases of spleno-medullary leukemia than in any 
other disease of the blood. In an occasional normoblast the 
contracted, glistening, intensely basic nucleus is highly sugges- 
tive of pyknosis. No one who has done much blood work can 
fail to be struck with the obvious avidity displayed by the stroma 
of the erythroblasts for the acid fuchsin of the triple stain — a 
peculiarity which is exhibited in spite of good technique and the 
use of a reliable staining solution. 

Deformities affecting the size and the shape of the erythrocytes 
may be trivial or decided, depending upon the degree of hemo- 
globin and erythrocyte loss present. Polycliromatophilia, alone, 
or associated with basophilic stroma degeneration, is very com- 
mon in cases with great anemia, the former especially affecting 
the nucleated erythrocytes, and the latter the non-nucleated cells. 

Striking increase in the number of leucocytes 

Leucocytes, is found even during the early stages of the dis- 
ease. Counts of from 200,000 to 300,000 cells 
to the cubic millimeter are common ; counts of from 300,000 
to 500,000 are less frequently observed ; but only occasionally 
does the estimate exceed the latter figure. In rare instances the 
number of leucocytes may be as high as 1,000,000 per cubic 
millimeter. It has been stated by competent authorities that the 
leucocyte count may equal or even exceed that of the erythro- 
cytes, and it is easy to see that such a condition is possible, 
should the accompanying oligocythemia be intense. In the esti- 
mates given in Table VII., showing the number of leucocytes at 
the time the patient first applied for treatment, the average count 
was 281,623 P er cubic millimeter, the highest being 544,000, and 
the lowest 44,000. The greatest number of leucocytes found in 
these cases at any time was 706,000, this estimate having been 
made a few hours before the patient's death. 

The number of leucocytes may fluctuate enormously at various 
times during the progress of the disease, a gain or a loss of some 
200,000 cells to the cubic millimeter from week to week being a 
matter of common occurrence. Sometimes they are temporarily 
diminished as the result of the administration of arsenic to the 
point of tolerance, or of the vigorous employment of other ther- 
apeutical measures ; sometimes the decrease takes place inde- 



SPLENO -MEDULLARY LEUKEMIA. 



251 



Table VII. 

Number of Leucocytes and Percentage of Various forms in Spleno- 
medullary leukemia, at the flrst examination. 12 cases. 









Percentage of Different Forms. 






No. 


Leucocytes per 






























cb. mm. 


Small lymph- 


Large lymph- 


Polymiclear 


Eosino- 


Myelo- 


Baso- 






ocytes. 


ocytes. 


Neutrophiles. 


phils . 


cytes. 


phil es. 


I 


544,000 


i-3 


5-6 


54-7 


5- 6 


-1/-. Q 
30.5 


2 


2 


450,000 


1.0 


2.2 


60.O 


28.7 


7-1 


I 


3 


446,420 


11. 0 


2-5 


60.5 


6.5 


19-5 




4 


370,000 


1,0 


9.0 


51.0 


5-o 


34-o 




5 


358,000 


2.0 


15.0 


63.O 


4.0 


16.0 




6 


285,000 


8.1 


10.0 


65-5 


4-5 


17-5 




I 


245,000 




8.0 


54-5 


9.0 


20.5 






222,300 


7.0 


15.0 


63.0 


4.0 


11. 0 




9 


168,750 


I.O 


6.0 


510 


12.0 


30.0 




10 


144,000 


I2.0 


18.0 


45-o 


4.0 


21.0 




11 


102,000 


0.7 


0.3 


73-6 


2.1 


23-3 




12 


44,00O 


6.8 


5-6 


70.8 


2.0 


14.8 




Av. 


281,623 


4-5 


8.1 


59-4 


7-3 


20.5 


-5 



pendently of the influence of remedial agencies, so far as can be 
determined. When arsenic is withheld the number of leucocytes 
promptly increases, and in spite of its use they ultimately increase, 
as the disease runs its fatal course. The relations of the leuco- 
cytes' fluctuations to the number of erythrocytes have already 
been mentioned. Hayek 1 has drawn attention to the fact that in 
the leukemic individual the morning leucocyte count may be 
greater by more than 100,000 cells per cubic millimeter than the 
estimate made during the afternoon, and vice versa. In a case in 
Professor Wilson's wards at the Jefferson Hospital, the writer 
has been able to verify this statement, the counts being as fol- 
lows : 1 1 a. m., 144,000 ; 6 p. m., 256,000 — a difference of 1 12,- 
OOO cells within a period of seven hours. The influences of di- 
gestion and other sources of error were, of course, excluded in 
making this observation. The occurrence of this enormous 
diurnal fluctuation emphasizes the importance of making the 
blood examination of leukemic patients at precisely the same hour 
each day, in cases studied for a long period. 

The possibility of encountering a case of leukemia during a 
period of remission, when the typical blood changes are absent, 
must be borne in mind, for such instances are observed from time 
to time, although they are very rare. For example, McCrae 2 
reports a case, treated by arsenic, in which twice during a period 

1 Wien. klin. Woch., 1897, vol. x., p. 475. 
2 Brit. Med. Journ., 1900, vol. i., p. 760. 



252 



DISEASES OF THE BLOOD. 



of ten months the blood and general symptoms of the patient 
were typical of spleno-medullary leukemia, and twice were abso- 
lutely normal. When first examined, this patient's leucocytes 
numbered 584,000 per cubic millimeter, three months later they 
had fallen to 9,250, two months after this they had risen to 178,- 
000, and after a lapse of another five months they again fell to 
5,000. These fluctuations did not depend upon the influence of 
any intercurrent infection (see below), and the case is unique in 
that the leucocytes (as well as the erythrocytes) not only were 
normal in number, but also normal qualitatively, and in that the 
patient's splenic tumor entirely disappeared during the periods 
of remission. Other cases have been recorded showing brief 
periods of temporary decline to normal in the number of leuco- 
cytes, but with the persistence of myelocytes, or of the splenic 
enlargement, or of both. 

The presence of myelocytes in large numbers is the hinge upon 
which the diagnosis of spleno-medullary leukemia must turn, for 
in no other disease are these cells so numerous, or so constantly 
present. A high percentage of myelocytes, irrespective of the 
degree of increase in the total number of leucocytes of all forms, 
is as essential for the diagnosis of this variety of leukemia as is a 
predominance of megaloblasts for the recognition of pernicious 
anemia. In most cases they constitute at least 20 per cent, of 
the different forms of leucocytes, and occasionally as high as 50 
per cent, or more. In the 1 2 cases of the present series (Table 
VII.) the myelocytes, at the first counts, averaged 20.5 per cent., 
with 7.1 and 34.0 per cent, as the minimum and maximum esti- 
mates, respectively. It is the fact, not that myelocytes simply 
occur in this disease, but that they occur in such enormous 
numbers, that is of prime value in the diagnosis, since in no other 
condition in which this type of marrow leucocyte is found in the 
blood, are they present in such striking abundance. For example, 
although myelocytes are very constant in pernicious anemia, they 
are only about one-twentieth as numerous in this disease, on the 
average, as they are in spleno-medullary leukemia. 

Many of the myelocytes are of very large size, some being 
quite 22 fx in diameter and occasionally of somewhat larger di- 
mensions ; others are dwarfed to no larger than the diameter of 
a small lymphocyte. The nuclei of these larger forms usually 
stain with relatively less intensity than those of the smaller. 
Indentation, apparent division, and hour-glass constriction of the 
myelocytes' nuclei are also frequently noted. A very common 
form of this cell in spleno-medullary leukemia is characterized by 
its large size and its pale, kidney-shaped nucleus, the regularly 



SPLEXO -MEDULLARY LEUKEMIA. 



253 



convex border of which lies in intimate contact with fully one- 
half the periphery of the cell body. These and other atypical 
forms of myelocytes are shown in the accompanying illustra- 

Fig. 39. 




12 3 456 

Atypical forms of myelocytes in spleno-medullary leukemia. 
(Ehrlich's triacid stain.) 

1, 2. Dwarf forms, with relatively large and deeply stained nuclei situated in a relatively small 
amount of cell body containing neutrophile granules. 3. " Fractured " myelocyte. 4. Extremely 
large form, with kidney-shaped nucleus. 5. Eosinophilic myelocyte with deeply constricted nucleus. 
6 Myelocyte having an hour-glass constriction of the nucleus. 

tion. The abnormalities affecting the granules of this type 
of cells, as well as certain degenerative changes, do not differ 
from those which are found in the polynuclear neutrophiles de- 
scribed below. 

The relative percentage of polynuclear neutrophiles is low, but 
not especially so, although of course the absolute number of 
this type of cells is greatly in excess of the normal standard, as 
may be demonstrated by taking into consideration the high total 
leucocyte count. For instance, in a case having 300,000 leuco- 
cytes per cubic millimeter, with, say, 50 per cent, of them poly- 
nuclear neutrophiles, the actual number of the latter is 150,000 
to the cubic millimeter, or fifteen times the maximum normal 
number. The cases listed in Table VII. averaged 59.4 per 
cent, for this variety of leucocytes, with a range between 45.0 
and 73.6 per cent, in the individual case, but other authors, 
with more extended series of cases as a basis for their statistics, 
give lower figures than these. 

A feature which at once attracts attention in the examination 
of the stained specimen is the deviation from the normal size of 
a large proportion of these neutrophilic cells. Dwarfed cells, 
often not more than 5 or 6 a in diameter, and large forms, some 
of them measuring 1 5 a or even more in diameter, are common, 
the nuclei of the former usually staining much more sharply than 
those of the latter, which may exhibit a very feeble reaction to- 
ward the basic dye, and show a more diffuse and delicate chro- 
matin structure than is the rule in normal blood. The nuclei 



254 



DISEASES OF THE BLOOD. 



also tend to exhibit extreme polymorphism and variations in their 
relative size to that of the cell body. Many of these cells are 
also deformed in shape, being drawn out into various oblong 
and elliptical designs or into irregular elongated masses. " Frac- 
tured" cells, from which the granules have escaped, are also 
commonly seen. It seems reasonable to attribute the free neu- 
trophilic granules sometimes seen in the blood in this disease to 
the rupture of a neutrophilic leucocyte, although the particular 
cell to which they belonged may be difficult to identify ; the view 
expressed by some authors that such granules may preexist in 
the plasma is scarcely to be thought of seriously. All of these 
deformities are doubtless the result of injuries to the cells in the 
preparation of the cover-glass spreads, and they suggest a lowered 
resistance on the part of the leucocytes. 

The number of granules in the polynuclear neutrophiles varies 
greatly in the individual cells ; in some they are densely crowded 
throughout the protoplasm and overrun portions of the nucleus ; 
in others they are confined to certain areas of the cell body, es- 
pecially in the neighborhood of the nucleus ; while in still others 
they are distributed singly or in twos and threes through the 
protoplasm. Occasionally a cell wholly devoid of granules is 
observed, and, very rarely, one containing both neutrophile and 
a few isolated eosinophile or basophile granules. The neutro- 
phile granules themselves vary greatly in size, being in some 
cells so extremely delicate and fine that they can be barely dis- 
tinguished, while in others they almost equal the size of the 
smaller eosinophile granules. 

Fig. 40. 

1 2 3 

Atypical forms of polynuclear neutrophiles in spleno-medullaky leukemia. 

1. Cell containing both neutrophile and moderately coarse basophile granules. 2. Polynuclear 
cell, with two ovoid nuclei and neutrophile granules, probably representing a later developmental 
stage than 6, Fig. 39. 3. " Fractured " polynuclear neutrophile. (No. 1 stained with Jenner's eosin- 
ate of methylene-blue, 2 and 3 with Ehrlich's triacid stain.) 

Fine and coarse vacuolation of the nucleus and protoplasm, a 
fissured and cracked appearance of the nuclear chromatin, and an 
apparent solution of the protoplasm with freeing of the nu- 
cleus are the most prominent degenerative changes affecting the 




CHART II. 




SPLENO- 
Red, Hemoglobin. 



MEDULLARY LEUKEMIA. 

Black, Erythrocytes. Blue, Leucocytes. 



SPLENO-MEDULLARY LEUKEMIA. 



255 



polynuclear neutrophils, as well as the other varieties of leuco- 
cytes, in this disease. 

The relative percentage of lymphocytes, small and large to- 
gether, is decidedly lower than normal, although their total num- 
ber to the cubic millimeter of blood is greatly increased. As 
shown by the cases in Table VII., these cells average a trifle 
more than 12 per cent, of all varieties of leucocytes, which rep- 
resents a diminution to about one-third of the proportion found 
in normal blood. It is the small lymphocytes which suffer the 
greater loss, for their proportion in the differential count is some- 
times not more than a fraction of 1 per cent., and always greatly 
below normal ; the large lymphocytes and " transitional " forms, 
on the contrary, average about normal, and, indeed, may be 
increased in the individual case. Turk's "stimulation forms" are 
also met with, but these cells as a rule are not numerous. 

Atypical forms of lymphocytes are not so common in this form 
of leukemia as they are in the lymphatic variety. Such cells are 
described under the latter disease. (See page 259.) 

Eosinophilia, as indicated by an increase in the total number of 
eosinophiles, is invariably found, and an increase above normal in 
the relative percentage of these cells sometimes, but not always, 
exists. Thus, in the above-mentioned series the eosinophiles, 
which normally do not exceed 500 per cubic millimeter, ranged 
from 880 to 129,150 and averaged 20,558 per cubic millimeter, 
these figures corresponding to percentages of 2.0, 28.7, and 7.3, 
respectively. 

Ehrlich's original statement regarding an increase of the eosino- 
philes in this form of leukemia has been contradicted by several 
writers, notably by von Limbeck, 1 and by Muller and Rieder 2 ; 
but these contradictions are based upon a misconception of Ehr- 
lich's remarks, for the latter never claimed that an abnormally 
high percentage of eosinophiles was associated with this disease, 
but said simply that their absolute number was increased. 

Marked variation in the size of many of the eosinophiles is com- 
monly observed, dwarf forms, 5 or 6 ju in diameter, with densely 
crowded and deeply stained granules, being especially striking 
and apparently more numerous than the larger forms. Eosino- 
philic myelocytes, differing from ordinaiy neutrophilic myelocytes 
only in that they are studded with eosinophile granules, are very 
numerous, and are among the largest forms of the myelocyte 
found in this disease. " Fractured" eosinophiles are common, 
being usually more abundant than neutrophilic cells which have 

1 Loc. cit. 

2 Deut. Archiv. f. klin. Med., 1891, vol. xlviii., p. 96. 



256 



DISEASES OF THE BLOOD. 



thus traumatically suffered. In some of the eosinophiles the 
granules are scanty, and in many their size varies greatly. Un- 
usually large-sized granules are often found, especially in the 
dwarf cells and in the extremely large forms. 

Basophiles, both the forms overcrowded with delicate, pure 
basic granules, and mast cells with relatively fewer, coarse, meta- 
chromatic granules, are found with great constancy, being absent 
in but a small proportion of cases. The latter type of cell is es- 
pecially suggestive of leukemia of this variety, since in no other 
disease does it occur in such large numbers. In some leukemic 
bloods the mast cells attain an enormous size, being quite the larg- 
est cellular elements found in the specimen. They may be 
easily identified by their characteristic reaction toward the basic 
dyes, described in a previous section. (See page 170.) 

From the above remarks, it may be concluded that myelocytes 
are present in the circulating blood at the expense of all the 
normal varieties of leucocytes except the eosinophiles, and that 
the brunt of this decrease is sustained by the mononuclear, non- 
granular forms, chiefly by the small lymphocytes. 

These bodies are greatly increased in number 
Blood in most cases of this form of leukemia, and may 
Plaques. frequently be recognized in the fresh specimen 
and in the diluted blood in the counting chamber 
of the hemocytometer. They are seldom observed, however, in 
the stained film prepared by ordinary methods. 

LYMPHATIC LEUKEMIA. 

In most cases the blood drop is watery-looking, 
Appearance pale, and thin, for in this variety of leukemia the 
of the anemia is usually very marked. The milky ap- 
Fresh Blood, pearance of the drop, frequently observed in the 
spleno-medullary form of the disease, is not often 
noticed in the lymphatic variety. 

The alterations in the coagulability, alkalinity, and specific 
gravity of the whole blood are similar to those met with in 
spleno-medullary leukemia. 

Microscopically, the field is crowded with large numbers of leu- 
cocytes, the vast majority of which are mononuclear cells encir- 
cled by a perfectly hyaline, non-granular protoplasm. They may 
be quite uniformly of either small or large size, or so many inter- 
mediate sizes may be present that it is impossible to distinguish 
any single predominating type. It is apparent that the leuco- 
cytes do not seem so numerous as in spleno-medullary leukemia, 
nor are their characteristics so striking, at first glance, because of 



PLATE V. 



12 



Lymphatic Leukemia. 
( Triacid Stain.) 



T ) 2 , 3, 4. 5. 6. Small Lymphocytes. 

These cells show a great difference in the intensity of their reaction toward the basic 
dye. The smallest forms, 1,2,4, and 5, being richer in nuclear chromatin and staining 
more deeply than the larger, 3 and 6. Compare 2 with the normoblast, 16, Plate IV. 

7, 8, 9, 10, 11. Large Lymphocytes. 

Except in 10, which shows a delicate rim of fuchsin-stained protoplasm, these lympho- 
cytes appear simply as pale chromatin-deficient nuclear structures, lacking cell "bodies. 
Compare these cells with the myelocytes, Plate IV. 

12. Transitional Form. 

The upper edge of the nucleus is somewhat indented and the protoplasm is distin- 
guishable; otherwise this cell resembles a large lymphocyte. 

(E. F. Faber, fee.) 



LYMPHATIC LEUKEMIA. 



257 



the entire lack of granulations in their protoplasm. The differ- 
ence between these hyaline cells and the granular leucocytes of 
the last-named disease, even although they may not happen to 
differ greatly in size and shape, is at once patent to the practised 
eye. The changes affecting the size, color, and shape of the eryth- 
rocytes vaiy with the degree of oligochromemia and oligocy- 
themia present ; they are generally quite decided, as in any high- 
grade anemia. 

Marked anemia, characterized by a dispropor- 
Hemoglobin tionate diminution in hemoglobin, is the general 
and rule in this variety of leukemia, the decrease in> 
Erythrocytes, both hemoglobin and eiythrocytes, especially in 
the former, being usually greater than in the 
spleno-medullary form. Compared with the latter, the hemoglo- 
bin loss averages about twice as much, the erythrocyte decrease 
is more than 10 per cent, greater, and the color index is just 30. 



Table VIII. 

Hemoglobin and Erythrocytes in Lymphatic Leukemia, at the First Ex- 
amination. 8 Cases. 



Number. 


Hemoglobin 


Color Index. 


Erythrocytes per 


Percentage. 


cb. mm. 


I 


29 


.40 


3,590,000 


2 


40 


.66 


3,000,000 


3 


31 


.58 


2,690,000 


4 


20 


•43 


2,310,000 


5 


23 


•5o 


2,266,000 


6 


18 


•5o 


1,800,000 


7 




•55 


1,270,000 


8 


25 


1.09 


1,152,000 


Average : 


25 


o.59 


2,259,750 



points lower. In the limited number of cases listed in Table VIII. 
the following estimates were obtained at the first examinations : 
average hemoglobin percentage, 25, ranging from 14 to 40 per 
cent. ; average erythrocyte count, 2,259,750, or from 1,152,000 
to 3,590,000 per cubic millimeter ; and average color index, 0.59, 
with a minimum of 0.40 and a maximum of 1.09. In rare in- 
stances the number of erythrocytes falls below 1,000,000, and the 
hemoglobin so low that it is impossible to estimate the percentage 
at all accurately. Rapidly developing and extremely pronounced 
anemia is generally observed in cases which pursue an acute course. 

Nucleated erythrocytes, chiefly of the normoblastic type, are 
commonly found in moderate numbers, but never, except in rare 
instances usually occurring in children, are they as numerous as 
17 



258 



DISEASES OF THE BLOOD. 



in the spleno-medullary form of the disease. As a rule, when 
both normoblasts and megaloblasts are present, the former vastly 
outnumber the latter, although occasionally one meets with a 
case in which this predominance of adult-type erythroblasts is 
less pronounced. Thus, in one of the writer's cases the total 
number of erythroblasts was calculated at 10,678 per cubic mil- 
limeter, of which 8,512 were normoblasts and 2,166 megalo- 
blasts ; such a blood-picture as this, however, is but seldom 
found. In general terms, it may be said that the more acute the 
form of the disease, the more decided the oligochromemia and 
oligocythemia, and the more abundant the erythroblasts, the 
number and character of which appear to depend upon the grade 
of the anemia present. It should not be forgotten that in some 
cases of typical lymphatic leukemia nucleated erythrocytes are 
so scanty that they are detected only after repeated examinations. 

Deformities of size and shape, and atypical staining of the eryth- 
rocytes are marked in direct relation to the severity of the anemia. 

The number of leucocytes is largely increased, 

Leucocytes, but usually much less strikingly so than in 
spleno-medullary leukemia, in which, generally 
speaking, their number averages about three times greater. In 
the latter it will be recalled that counts of between 200,000 and 
300,000 cells to the cubic millimeter are the rule, but in the lym- 
phatic form it is only in comparatively rare instances that the 
estimate exceeds 100,000. Counts of 500,000 or even of 1,000- 
000 cells have, it is true, been reported by a few observers, but 
only as rare examples of the extreme increase which it is pos- 
sible for the leucocytes to attain in this condition. The cases in 
Table IX. show an average of 88,438 cells to the cubic milli- 



Table IX. 

Number of Leucocytes and Percentage of Various Forms in Lymphatic 
Leukemia, at the First Examination. 8 Cases. 





Leucocytes per 




Percentage of Different Forms. 






No. 






























cb. mm. 


Total lym- 


Small lym- 


Large lym- 


Polynuclear 


Eosino- 


Myelo- 






phocytes. 


phocytes. 


phocytes. 


neutrophiles. 


philes. 


cytes. 


I 


120,000 


53-o 


28.O 


25.O 


45-o 


2.0 


O.O 


2 


119,500 


97-7 


63.2 


34-5 


2.0 


O.O 


°-3 


3 


115,000 


90.O 


33-o 


57-o 


9.9 


O.I 


0.0 


4 


96,000 


92.0 


28.8 


63.2 


6.1 


O.O 


1.9 


5 


88,000 


89.O 


25.2 


63.8 


5.6 


o-5 


4.9 


6 


85,000 


97.0 


28.0 


69.0 


3-o 


0.0 


0.0 


7 


4.6,000 


97-3 


21. 1 


76.2 


1.6 


0.0 


1.1 


8 


38,000 


9i-3 


21.3 


70.0 


7? 


0.0 


1.6 


Av. 


88,438 


88.4 


3ii 


57-3 


10. 0 


o-3 


1.2 



LYMPHATIC LEUKEMIA. 



259 



meter, with a minimum of 38,000, and a maximum of 120,000. 
It may be noted that a few of these cases showed an increase not 
much greater than can be found in a high-grade leucocytosis. 

By examination of the stained film, the identity of the leuco- 
cytes responsible for the high count is more clearly distinguish- 
able, and it is found that the increase is due to a large absolute 
gain in the lymphocytes, the relative percentage of these cells to 
the other varieties of leucocytes generally being 90, or 95, 
or even higher. In the series above summarized (Table IX.) 
these non-granular cells averaged 88.4 per cent, of the leuco- 
cytes, and equalled or exceeded 90 per cent, in three-fourths of 
the cases examined. In some instances the small lymphocytes 
are found to be in excess, and the field is dotted with small, 
deeply stained cells ranging from about 5 to 10 p. in diameter; 
in other instances the larger forms prevail, so that large, feebly 
stained cells, from about 10 to 15 [jl, or even larger, are in excess ; 
while in still other cases the sizes and staining properties of the 
cells are so variable and atypical that it is impracticable to class 
them in two definite groups, large and small. It is generally 
believed that small lymphocytes are associated with the more 
chronic forms of the disease, and that the larger varieties are 
found in excess in the acute cases. Many of the larger forms, 
which possess a relatively large nucleus deficient in chromatin 
and a faintly basic non-granular protoplasm, are regarded as the 
mother-cells of the typical small lymphocytes. They are iden- 
tical with the " lymphogonien " of Benda and the " leukoblasts " 
of Lowit, cells resident in the germinal nests of the lymphatic 
tissues. In the triple stained specimen they bear a certain re- 
semblance in size and shape to the myelocytes, but differ from 
them in having a protoplasm devoid of neutrophile granules. 

Various atypical forms of lymphocytes, the commonest of 
which are pictured below (Fig. 41), are often numerous. With 
basic stains, such as methylene-blue, a ragged, torn condition of 

Fig. 41. 




1 2 3456 

Atypical forms of lymphocytes in lymphatic leukemia. 

1. Large lymphocyte with ragged protoplasm. Two small bits of protoplasm, the product of 
" budding," lie free in the plasma beside the cell. 2. Large lymphocyte showing a nucleolus. 3. 
Large lymphocyte containing two nuclei. 4. Small lymphocyte containing an indented nucleus. 5. 
Small lymphocyte containing two nuclei. 6. Cell the size of a large lymphocyte with the nucleus of 
a small lymphocyte. (1 and 2 are stained with eosin and methylene-blue, 3, 4, 5, and 6 with Ehrlich's 
triacid stain.) 



260 



DISEASES OF THE BLOOD. 



the basic seam of protoplasm, and so-called " budding" of the 
protoplasm are frequently demonstrable, as well as nucleolation of 
some cells, especially of those of large size. Nuclear indentation 
and division, and forms characterized by a small lymphocyte's 
nucleus within a large lymphocyte's cell body are also common. 

The relative proportion of polynuclear neutropkiles is markedly 
diminished, commonly to from about 5 to 10 per cent, of the 
total number of leucocytes, and sometimes even to below 1 per 
cent. These cells do not usually display the abnormal staining 
and nuclear characteristics and irregularities in size and shape 
that are so often seen in spleno-medullary leukemia. 

Myelocytes are present in the great majority of cases, but al- 
ways in trifling numbers, as in pernicious anemia ; their propor- 
tion rarely exceeds 1 or 2 per cent, of all forms of leucocytes. 

The percentage of eosinophils is diminished, usually to a frac- 
tion of I per cent., and in a certain proportion of cases these cells 
are absent from the peripheral blood. It must be remembered, 
however, that even with a low relative percentage figure for the 
eosinophiles, true eosinophilia may exist, although usually not to 
such a marked degree as in the spleno-medullary form of the 
disease. One per cent, of eosinophiles in a leucocyte count of 
100,000 means 1,000 eosinophiles per cubic millimeter of blood, 
or twice the maximum number found in the normal individual. 
Eosinophilic myelocytes are rare, but they occur in small numbers 
in an occasional case. 

Increase in the number of basopliiles has been observed only 
exceptionally, and both the finely granular basophilic leucocytes 
and the typical mast cells are generally conspicuous by their 
absence, in contrast to their abundance in the spleno-medullary 
variety of this disease. 

From the above, it is evident that in lymphatic leukemia the 
increase in the total number of leucocytes is dependent upon a 
marked absolute gain in the lymphocytes, and that in conse- 
quence of this enormous influx of mononuclear hyaline forms, 
the relative percentages of the other leucocytes, especially of the 
polynuclear neutrophiles, are correspondingly diminished. 

As in the spleno-medullary form, the number of blood plaques 
is usually much increased. 

This term has been applied to a form of leu- 
Acute kemia which pursues a rapid course suggestive 

Leukemia, of an acute infectious process, and ends fatally 
within a few weeks after the onset of the acute 
symptoms. Rapid, progressive enlargement of the lymphatic 
glands and a relatively small splenic tumor, associated with such 



LYMPHATIC LEUKEMIA. 



26l 



clinical features as rigors and irregular pyrexia, bone pains, ulcer- 
ative stomatitis, a decided tendency to hemorrhages from the 
mucous membranes and to purpura, serve to identify this rapidly 
fatal variety of the disease. Some authors limit the duration of 
acute leukemia to six weeks, but the time limit proposed by Fraen- 
kel, 1 four months, is generally accepted as being more appropriate. 

The disease is a rare one, for probably fewer than seventy-five 
authentic cases have been recorded up to the present time, al- 
though many more reputed instances have been published. Eb- 
stein 2 collected seventeen cases, in 1 889 ; Fraenkel 3 published the 
statistics of ten, in 1895 ; Bradford and Shaw 4 described, in 1898, 
five cases coming under their observation ; and Fussell, Jopson 
and Taylor, 5 in the same year, published a collective report, em- 
bracing the statistics of fifty-seven cases selected as representing 
all the true examples of acute leukemia reported during the past 
twenty-one years. Since this report about a dozen additional 
cases have been described by various observers. 

Beyond stating that lymphemia is the type of blood character- 
istic of acute leukemia, no special description of the condition of 
the blood is necessary. In the majority of cases the leucocyte 
increase may be attributed to a marked gain in the large lympho- 
cytes, which greatly predominate over the small forms, while the 
polynuclear neutrophiles, myelocytes, and eosinophiles are rela- 
tively few in number. As a rule, the more acute the case, the 
more decided the predominance of the large lymphocytes, which 
usually show well-marked evidences of nuclear and protoplasmic 
degenerative changes. The loss of hemoglobin and erythrocytes 
is generally more marked, and the erythroblasts are more numer- 
ous than in the commoner forms of chronic lymphatic leukemia. 

Acute leukemia may begin as such, or either the chronic lym- 
phatic or spleno-medullary form may develop acute symptoms, 
with a coincident change in the condition of the blood, but this 
change in the spleno-medullary form is extremely rare. 

The development of an acute infectious process 
Influence of in a leukemic individual commonly provokes 
Acute Inter- striking changes in the behavior of the leucocytes, 
current In- consisting in most instances in a decrease of their 
fections. total number to the cubic millimeter of blood, as- 
sociated sometimes with an increase in the poly- 
nuclear variety of cells and a relative diminution in the number 

1 Deut. med. Woch. , 1895, vol. xxi., p. 639 et seq. 
2 Deut. Archiv. f. klin. Med., 1889, vol. xliv., p. 343. 
3 Loc. cit. 

* Medico- Chirurg. Trans., London, 1898, vol. lxxxi., p. 343. 
5 Trans. Assn. Am. Phys., Phila., 1898, vol. xiii., p. 124. 



262 



DISEASES OF THE BLOOD. 



of myelocytes. At other times there is practically no alteration 
in the relative proportions of the different forms as they existed 
in the leukemic blood prior to the onset of the complicating in- 
fection. Among the infectious conditions acting in this manner 
on the leucocytes are abscess, sepsis, pneumonia, influenza, 
miliary tuberculosis, and erysipelas, but it seems that rheumatic 
fever has no such effect. Weil, 1 who has studied the effects of 
colon, pneumococcus, and streptococcus infections in both forms 
of leukemia, comes to the conclusion that the most powerful in- 
fluence upon the blood-picture is exerted by streptococcus infec- 
tions. Malignant disease is also capable of bringing about a leu- 
cocyte decrease characterized by a relative gain in polynuclear 
neutrophiles at the expense of the lymphocytes, but the loss does 
not appear to be so decided as that excited by a specific infec- 
tious process. 

Two cases reported by Fraenkel 2 may be cited to illustrate the 
extreme decrease which the leucocytes may suffer under such 
influences and the rapidity with which the loss may take place. 
In one of this author's cases, five days after the beginning of a 
staphylococcus infection the patient's leucocytes began to fall, 
their number decreasing from 89,000 to 6,000 within a period of 
two weeks ; while in a second case the count fell from 220,000 
to 1,200 within a few days, the change in this instance also being 
attributed to a septic process. In a patient with spleno-medullary 
leukemia and septicemia, reported by Kormoczi, 3 the leucocytes, 
which numbered 100,000 per cubic millimeter at the first exami- 
nation, fell to 3,000 on the day of death, the myelocytes practic- 
ally disappearing from the blood, and a moderate increase in the 
lymphocytes occurring during the last few days of life. Eisen- 
lohr 4 has recorded a similarly marked decrease in the leucocytes 
in the same type of the disease, the complicating infection being 
enteric fever ; Miiller 5 has observed a fall from 109,000 to 6,800 
in a case of acute leukemia in which a staphylococcus infection 
had developed ; and a number of other writers have reported ex- 
amples of more moderate leucocyte decreases due to various in- 
fectious diseases. 

Coincident with the improvement in the condition of the blood, 
there is frequently a decrease in the size of the patient's enlarged 
spleen and lymphatics, the period during which the leukemic 
condition is thus bettered and, so to speak, held in abeyance, 

1 Gaz. bebdom. de med. et de chir., 1900, n. s., vol. v., p. 829. 
2 Loc. cit. 

3 Deut. med. Woch., 1899, vol. xxv., p. 773. 
4 Virchow's Archiv., 1878, vol. lxxiii., p. 56. 
5 Jahrb. f. Kinderbeilk., 1 896, vol. xliii., p. 130. 



LYMPHATIC LEUKEMIA. 



263 



corresponding to the duration of the complicating infection, for 
the blood gradually regains its leukemic type and the glandular 
and splenic tumors reappear, as recovery from the intercurrent 
disease takes place. 

In rare instances the occurrence of an infectious disease fails to 
cause a decrease in the leucocytes, and thus to destroy the leu- 
kemic picture, but on the contrary increases them, by superim- 
posing a typical polynuclear neutrophile leucocytosis, which re- 
mains during the existence of the complicating infection the 
more conspicuous feature of the blood. The writer has observed 
a typical illustration of such a change in a case of spleno-medul- 
lary leukemia, in which within ten days after the onset of a com- 
plicating peritonitis, the leucocyte count rose from 245,000 to 
400,000, and the proportion of polynuclear neutrophiles from 
44.5 to 79 per cent., while the percentage of myelocytes fell 
from 20.5 to 8. A somewhat similar change has been observed 
by Miiller, 1 in a patient with lymphatic leukemia, the increase in 
leucocytes having been 220,000, and the gain in polynuclear 
neutrophiles noteworthy. 

Diagnosis ^ e ^°^ owm ? blood-picture is characteristic of 
the spleno-medullary variety of leukemia : 



Hemoglobin. 
Erythrocytes. 



Decided loss, averaging about 50 per cent, 
index subnormal, 



Color 



or high. 



Leucocytes. 



Plaques. 



Counts average about 3,000,000 per cubic milli- 
meter. 

Erythroblasts very numerous, cells of the normo- 
blastic type predominating. 

Deformities of size and shape, polychromatophilia, 
and basophilic stroma degeneration marked in cases 
with severe anemia. 

Increased to about 300,000 per cubic millimeter, 
counts in excess of this figure being comparatively 
rare. 

Myelocytes constitute about 20 per cent, of all 
forms. 

Relative percentageof polynuclear neutrophiles low. 
Relative percentage of lymphocytes very low. 
Eosinophiles absolutely, sometimes relatively, in- 
creased. 

Basophiles increased, especially the mast cells. 
Atypical forms of neutrophiles numerous. 

Increased. 



Deut. Archiv. f. klin. Med., 1892, vol. xlix., p. 47. 



264 



DISEASES OF THE BLOOD. 



In lymphatic leukemia the blood changes may be briefly ex- 
pressed thus : 

Hemoglobin. Marked loss, averaging about 75 per cent. Color 
index low. 

Erythrocytes. Counts average about 2,250,000 per cubic milli- 
meter. 

Erythroblasts usually scanty, cells of the normo- 
blastic type predominating. 

Deformities of size and shape, and atypical staining 
reaction marked in relation to the degree of anemia 
present. 

Leucocytes. Increased to about 100,000 per cubic millimeter, 
counts above this figure being rare. 
Lymphocytes constitute about 90 per cent, of all 
forms. 

Relative percentage of polynuclear neutrophiles 
strikingly low. 

Relative percentage of eosinophiles diminished ; 
rarely, an absolute increase. 
Small numbers of myelocytes frequent. 
Basophiles usually not increased. 
Atypical forms of lymphocytes numerous. 
Plaques. Increased. 

In dealing with the differential diagnosis of leukemia it is nec- 
essary to distinguish the spleno-medullary from the lymphatic 
form, and also to differentiate both forms of the disease from a 
number of other conditions which may present either somewhat 
similar blood findings, or which, apart from the condition of the 
blood, may have closely similar clinical manifestations. Thus, on 
the one hand, leucocytosis and lymphocytosis require differentia- 
tion because they produce changes in the blood which may be 
confused with leukemia; while, on the other hand, we must dis- 
tinguish between leukemia and Hodgkin's disease, splenic anemia, 
and a number of conditions causing enlargements of the spleen, 
neighboring organs, and lymphatic glands because of the resem- 
blance, even identity in some instances, of the other clinical 
signs. 

Spleno-medullary and lymphatic leukemia can be distinguihsed 
only by examination of the blood, for the distinction between 
these two forms of the disease cannot be based with any degree 
of certainty upon the gross clinical appearance of the spleen and 



LYMPHATIC LEUKEMIA. 



265 



lymphatics. Nothing can be more marked than the contrast be- 
tween the two blood-pictures. In the spleno-medullary form the 
leucocyte count is usually much higher, and is associated with the 
presence of immense numbers of myelocytes, and with an increase 
in the eosinophils and usually in the basophiles ; the oligocythe- 
mia is not so marked, but erythroblasts are exceedingly numerous, 
and, strangely, tend to persist independently of any increase in the 
erythrocytes which may occur from time to time. In the lym- 
phatic form the relatively moderate leucocyte increase depends 
upon an excessive gain in the ungranulated cells, or lymphocytes, 
myelocytes being either absent or present in trifling numbers, and 
decided increase in the eosinophiles and basophiles being most 
unusual ; the oligocythemia is usually decided, but erythroblasts 
are scanty, and stand in relationship to the degree of anemia 
existing. The important points of difference are, therefore, the 
presence of a myelocytic blood in the spleno-medullary form, 
and of a lymphocytic blood in the lymphatic variety. 

Pathological leucocytosis may occasionally involve an increase 
in the total number of leucocytes equal to that found in either 
form of leukemia, especially in those cases in which a period 
of temporary improvement with a fall in the leucocyte count 
exists. But, aside from the more or less temporary character of 
the increase in leucocytosis, the differential count at once shows 
that, unlike leukemia, the gain depends upon a large absolute and 
relative increase in the polynuclear neutrophiles, which constitute 
ordinarily 90 per cent, or more of the several forms of leuco- 
cytes. 

Lymphocytosis, which is usually a relative condition, may in rare 
instances become absolute, so that, in addition to the increase in 
the relative percentage of lymphocytes, the total number of leu- 
cocytes in the blood is also decidedly increased. In marked in- 
stances of this sort it is obviously impossible to distinguish the 
blood change from that of lymphatic leukemia, and the aid of 
other clinical symptoms must be invoked to make the diagnosis 
clear. Thus, both an absolute and relative lymphocytosis, closely 
simulating the lymphatic form of leukemia, have been observed in 
severe cases of chlorosis, in pertussis, in sarcoma of the lymphatic 
structures, and in acute inflammatory processes occurring in 
young children. The author recalls an instance of marked abso- 
lute lymphocytosis in a case of pernicious anemia, which seemed 
to justify the tentative diagnosis of lymphatic leukemia, an error 
which was later corrected, when the megaloblastic blood-picture 
became apparent. In such instances, which are fortunately of 
very rare occurrence, it is true that neither the percentage of 



266 



DISEASES OF THE BLOOD. 



lymphocytes nor the count of leucocytes is likely to average as 
high as in lymphatic leukemia, but still the blood changes are 
sometimes very misleading, and should not be relied upon to the 
exclusion of other equally important symptoms. 

The glandular and splenic enlargements of Hodgkiri s disease 
form a clinical picture identical with either the spleno-medullary 
or the lymphatic variety of leukemia, so that these conditions are 
distinguishable only by the result of the blood examination. But 
by this means the diagnosis is made extremely simple, by finding 
in Hodgkin's disease either entirely normal blood or a variable 
degree of anemia. The number of leucocytes is usually nor- 
mal, except in cases in which some complicating inflammatory 
or infectious process causes a moderate increase, typical of a 
polynuclear neutrophile leucocytosis. 

The rather close resemblance which certain cases of splenic 
anemia bear to leukemia, together with the points of difference 
between these two diseases, have already been described. (See 
page 235.) 

Enlargements of the spleen, left kidney ', and pancreas may lead 
to the inference that leukemia exists. Thus, splenic tumors due 
to chronic malarial infection, to amyloid disease, to cysts, and to 
malignant neoplasms ; enlargements of the left kidney such as 
can be caused by hydronephrosis, by cysts, and by malignant 
disease ; as well as cystic tumors of the pancreas and malignant 
disease of the retroperitoneal glands all may, on physical exami- 
nation, simulate more or less faithfully the leukemic spleen. The 
negative character of the blood findings will at once exclude leu- 
kemia, should one of the above-named conditions be the cause 
of the physical signs suggesting this disease. 

Lymphatic hyperplasia, due to tuberculosis, to syphilis, and to 
malignant disease may also be mistaken for the glandular in- 
volvement of leukemia, for such enlargements sometimes show 
nothing distinctive. In tuberculous adenitis the blood is either 
normal, or anemic, if the cachectic state of the patient is marked ; 
or, should there happen to be a secondary infection of the glands 
plus the tuberculous lesions, a simple polynuclear leucocytosis 
is found. In syphilitic adenitis there is often anemia with a mod- 
erate polynuclear leucocytosis, and sometimes with a relative 
lymphocytosis, especially in children. In malignant disease of 
the lymphatics increase in the number of leucocytes may also be 
noted, in association with a high-grade anemia ; in carcinoma the 
increase involves chiefly the polynuclear neutrophiles, but in sar- 
coma the lymphocytes may be unduly increased, though not to 
the extent found in lymphatic leukemia. 



hodgkin's disease. 



267 



VII. HODGKIN'S DISEASE. 

Nothing characteristic is observed either in the 
Appearance gross appearance of the fresh blood drop, or in 
of the the unstained film, microscopically. The blood 
Fresh Blood, may appear normal, or it may show changes 
common to any secondary anemia. 
The alkalinity and specific gravity of the whole blood are di- 
minished in relation to the degree of anemia which exists. Coag- 
ulation may take place slowly, or even be as incomplete as it is 
reported to be in some cases of leukemia ; or it may occur within 
the normal time limit. 

The hemoglobin percentage and the number 
Hemoglobin of erythrocytes are both normal in the early 
and stages of the disease, and in slowly progressive 
Erythrocytes, cases the blood may remain unaffected for a long 
period. But sooner or later, as the disease pro- 
gresses and a cachectic condition of the patient develops, anemia 
appears, gradually where the course of the disorder is slow, and 
rapidly in the more acute forms. Counts made when the patient 
first comes under observation usually average 4,000,000 or 5,- 
000,000 cells per cubic millimeter, but in the later stages the 
number frequently falls to one-half this figure or even less. The 
loss of hemoglobin begins earlier, and in most instances is pro- 
portionately somewhat greater, than the erythrocyte decrease, so 
that subnormal color indices rule — not decidedly low, but yet 
twenty points or so below the normal standard. In cases which 
develop excessive oligocythemia the index figures may be quite 
as high as in pernicious anemia. 

In the series of 10 cases summarized in Table X., the hemo- 
globin averaged somewhat less than 60 per cent., ranging be- 
tween 30 and 82 per cent; the erythrocyte count averaged 
3,853,700 per cubic millimeter, the minimum being 2,207,000 and 
the maximum 5,225,000, with one-half the cases having 4,000,- 
000 cells or more ; and the average color index was 0.78, or from 
0.36 to 1. 17. 

Qualitative changes affecting the corpuscles occur in relation 
to the intensity of the anemic process, deformities of shape and 
size and atypical staining reaction of the cells being associated 
with cases in which notable hemoglobin and erythrocyte losses 
exist, and being absent when the anemia is moderate. Nucle- 
ated erythrocytes are not common, nor are they numerous when 
present. Usually none are found, except in connection with a 
high-grade anemia, under which circumstance a few normoblasts 



268 



DISEASES OF THE BLOOD. 



Table X. 



Hemoglobin and Erythrocytes in Hodgkin's Disease, at the First 
Examination, io Cases. 



Number. 


XT GlXlOgrO Din 


Color Index. 


Erythrocytes per 


Percentage. 


cb. mm. 


I 


82 


.78 


5,225,000 


2 


8o 


.78 


5,100,000 


3 


65 


.72 


4,500,000 


4 


30 


.36 


4,200,000 


5 


60 


•75 


4,000,000 


6 


46 


.66 


3,470,000 


7 


52 


•77 


3,360,000 


8 


5o 


•76 


3,275,000 


9 


75 


1. 17 


3,200,000 


io 


45 


1.02 


2,207,000 


Average : 


58.5 


.78 


3> 8 53>7oo 



may be detected, and in rare instances an occasional megaloblast. 

In the average case the leucocytes are normal, 
Leucocytes, both in number and in the relative percentage of 
different varieties. More rarely, relative lym- 
phocytosis occurs, involving a decrease in the percentage of 
polynuclear neutrophiles, but not increasing the total number of 
leucocytes. An instance of this kind has been observed by 
the writer, in which the relative proportion of lymphocytes to 
other forms of leucocytes habitually remained for some months 
between 70 and 85 per cent, this change affecting chiefly the 
large lymphocytes, while the total leucocyte count never ex- 
ceeded normal. 

Table XL 



Number of Leucocytes and Percentage of Various Forms in Hodgkin's 
Disease, at the First Examination, io Cases. 



No. 


Leucocytes per 
cb. mm. 


Percentage of Different Forms. 


Small Lym- 
phocytes. 


Large Lym- 
phocytes. 


Polynuclear 
Neutrophiles. 


Eosinophiles. 


Myelocytes. 


I 

2 
3 

4 
5 

6 

7 

8 

9 
10 


21,000 
I9,O0O 
16,000 
12,000 
Il,900 
9,300 
7,000 
4,000 
3,600 
1,000 


5-5 

4.0 
27.2 

5-6 
23.O 

8.0 

29.5 
25.O 
I8.I 
6.0 


4-5 
12.0 
12.8 
36.6 
12.0 
18.0 

14-5 
4.0 

3.0 
16.0 


89.O 
81.6 
58.8 

56.3 
64.O 
7I.O 

53-0 
68.O 

75-6 
76.O 


I.O 

1.6 
1.2 

1.5 
1.0 

3-o 
3-o 
2.0 

2-5 

2.0 


O.O 
O.8 
O.O 
O.O 
O.O 
O.O 
O.O 
I.O 
O.8 
O.O 


Av. 


10,480 


IS! 


13-3 


69-3 


1.8 


0. 26 



HODGKIN S DISEASE. 



269 



If secondary infection takes place, it soon becomes evident by 
an increase in the leucocytes to about 20,000 or more, principally 
involving the polynuclear neutrophile cells, at the expense of the 
lymphocytes — a picture of typical leucocytosis. In some in- 
stances, however, without any apparent signs of a secondary in- 
fection or of a glandular inflammation, the total count may ex- 
ceed the normal standard by several thousand cells, and yet show 
a normal or even somewhat increased proportion of lymphocytes. 
Should the anemia be very marked, pronounced leucopenia is 
commonly associated with it. In the present series (Table XI.) 
one-half of the cases showed leucocyte counts above, and the 
other half below, 10,000 cells to the cubic millimeter, the highest 
estimate being 21,000, the lowest 1,000, and the average 10,480. 

Small numbers of myelocytes are not uncommon in the ad- 
vanced anemia of Hodgkin's disease, but they are never more 
numerous than in any other condition accompanied by a similar 
deterioration of the blood. 

Small numbers and low percentages of eosinophiles are the 
rule, both in cases with and without leucocytosis ; it is most un- 
usual for these cells to attain the maximum normal figure, and 
they are sometimes wholly absent. 

Neither the finely granular basophiles, nor the typical mast cells 
are increased in this disease. 

As in both forms of leukemia, the number of blood plaques in 
Hodgkin's disease is usually increased. 

Although no characteristic blood changes oc- 

Diagnosis. cur in this condition, the alterations most com- 
monly observed may be briefly summed up as 
follows : 

Hemoglobin. Normal in the early stages of the disease ; later, a 
moderate decrease, estimates averaging about 60 
per cent. Color index commonly subnormal, 
rarely high. 

Erythrocytes. Normal in the early stages ; later, a variable degree 
of oligocythemia, counts averaging about 3,750,- 
OOO per cubic millimeter. 

Erythroblasts uncommon, and scanty when present. 
Normoblasts prevail almost exclusively, megalo- 
blasts being very rare. 

Deformities of size and shape, polychromatophilia, 
and basic stroma degeneration only in cases with 
high-grade anemia. 



DISEASES OF THE BLOOD. 



Leucocytes. Normal, or moderately increased. 

Either polynuclear neutrophiles or lymphocytes 
may be relatively increased, more commonly the 
former. 

Small numbers of myelocytes in greatly anemic 
cases. 

Eosinophiles not increased. 
Basophiles not increased. 

Plaques. Usually increased. 

The absence of characteristic blood changes in Hodgkin's 
disease at once distinguishes the condition from its clinical coun- 
terfeit, leukemia, but aside from this single disease, the blood ex- 
amination is valueless in the differentiation of other conditions 
having somewhat similar involvement of the glandular structures. 
These conditions, tuberculous and syphilitic adenitis, local lympho- 
matous tumors, and malignant neoplasms of the lymphatics, must 
therefore be distinguished from Hodgkin's disease by other clin- 
ical methods, for they all may provoke identical blood changes. 

In reviewing the clinical history of a case of suspected Hodg- 
kin's disease, the following symptoms should be given special 
consideration : the gradual onset of a widespread hyperplasia of 
the lymphatic structures, occurring most commonly in males 
under middle age ; the progressive character and chronicity in 
most cases of the disorder ; the tendency in some cases toward 
the occurrence of unexplained febrile periods, sometimes coincid- 
ing with a rapid and marked increase in the size of the affected 
glands which disappears as the fever subsides ; the cachexia, 
asthenia, and emaciation of the patient, frequently associated with 
gastro-intestinal and circulatory disturbances, and with a tendency 
to hemorrhages, such as epistaxis and purpura ; the presence of 
pressure symptoms, such as cough, dysphagia, dyspnea, edema, 
and pleural and peritoneal effusions ; and the development of 
bronzing of the skin in an occasional case. 

In typical cases, the glandular enlargement forms a series of 
distinct, painless, hard tumors, each freely separable from its 
neighbor, and rarely caseating or suppurating. Due weight 
should also be given to the fact that in the majority of cases the 
lesion originates in the superficial lymphatic glands of the cervical 
region, beginning either in the occipital or in the inferior carotid 
triangle. The spleen is moderately enlarged in the majority of 
cases, and in others the liver, kidneys, suprarenals, tonsils, 
thymus, thyroid, and sexual organs may be involved in the 
lymphoid growths. 



hodgkin's disease. 



271 



Tuberculous adenitis usually first involves a group of glands in 
the submaxillary triangle, and tends to produce inflammatory 
adhesions between the tissues and the glandular structure, and 
softening, fusing, caseation, and suppuration of the glands. It is 
of sluggish development, often occurs in the veiy young, and is 
almost always confined to a single group of glands. Evidences 
of tuberculous lesions in the lungs or in other parts of the body, 
especially of dental caries, cutaneous lesions of the face, and ade- 
noid pharyngeal groAvths, and the discovery of tubercle bacilli in 
the glandular tissue are valuable evidences of the tuberculous 
nature of the disease, yet they do not positively exclude Hodg- 
kin's disease, since the coexistence of the two conditions in the 
same individual, although rare, is possible beyond a doubt. 

In syphilitic adenitis of the neck the post-cervical groups are 
first affected, the glands being of cartilaginous hardness, painless, 
freely movable, and of small or moderate size. The glandu- 
lar enlargement is often more or less general, but the affected 
groups do not attain a large size. A histoiy of an initial lesion 
in the vicinity of the primary glandular swellings, or of the 
appearance of secondary symptoms, the disappearance of the 
glandular tumors after the administration of mercury, and the 
presence of Justus' test will suffice to prove the specific character 
of the hyperplasia. 

A local lymphoma is limited strictly to a single group of glands, 
forming a painless, dense mass, free from inflammatory adhesions, 
caseation, and suppuration. It commonly involves the submaxil- 
lary glands, may attain a large size, and is unassociated with con- 
stitutional symptoms. Such a local lymphatic tumor cannot be 
distinguished from the early stage of Hodgkin's disease, for in 
some cases of the latter the general lymphoid hyperplasia is pre- 
ceded by a period during which the only sign of the condition is 
a localized enlargement of a single group of glands. If, accord- 
ing to Osier, 1 a local glandular tumor of this kind persists for 
over a year or eighteen months without involving the glands of 
the opposite side or of the axilla, it is almost certainly a non- 
malignant lymphoma. 

Sarcoma of the lymphatic tissue forms an immovable tumor, 
early complicated by inflammatory processes which cause inter- 
glandular adhesions and adhesions between the glands and the 
surrounding tissues. The swelling is often red and inflamed, pits 
upon pressure, and resembles an abscess, while the skin over the 
site of the lesion is frequently marked by a maze of tortuous, 
congested, cutaneous veins, and is prone to ulcerate. The adja- 

1 Cited by Bramwell : "Anemia," etc., Phila., 1899, p. 203. 



272 



DISEASES OF THE BLOOD. 



cent tissues become densely infiltrated by the sarcomatous growth, 
and involvement of distant organs by metastasis is likely to occur. 
If nerves are entangled in the growth, the tumor is exquisitely 
painful. Sarcoma of the lymphatic glands may occur at any 
period of life. 

Carcinoma of the lymphatic glands is secondaiy to an initial 
growth in some other part of the body, so that in the region of 
the neck search should be made for a primary cancerous lesion 
in the mouth and upper air passages. The disease is most com- 
monly found during the decline of life. 

Finally, as Tyson so pertinently remarks, 1 it should not be for- 
gotten that all the conditions named as possible to be mistaken 
for Hodgkin's disease are limited to a single group of glands, 
while Hodgkin's disease always extends, and the fact of such 
limitation is of itself sufficient to preclude the disease. This pro- 
gressive involvement of the lymphatic glands, group after group, 
must, after all, be our mainstay in the diagnosis of doubtful cases 

VIII. THE EFFECT ON THE BLOOD OF SPLENEC- 
TOMY. 

Excision of the spleen in man is followed by a 
Hemoglobin diminution in the hemoglobin and erythrocytes, 
and the degree of which is generally believed to be 
Erythrocytes, more pronounced than can be accounted for by 
the simple factor of hemorrhage incident to the 
operation. Blood regeneration is slow, especially the restoration 
of the hemoglobin, which is prone to increase much less rapidly 
than is the rule in an ordinary secondary anemia. In uncompli- 
cated cases from one to three months' time usually elapses be- 
fore the normal percentages of hemoglobin and erythrocytes are 
attained ; in unfavorable cases persistence of the anemia for a 
much longer period is to be observed. Splenectomies attended 
by great loss of blood may excite, in addition to an extreme cel- 
lular decrease, striking qualitative changes, and in such instances 
the blood-picture is characterized by the presence of many normo- 
blasts, achromacytes, and corpuscles deformed in shape and size. 
Conspicuous post-operative anemia is especially common in pa- 
tients to whom saline intravenous injections have been administered. 

Post-operative leucocytosis of the polynuclear 
Leucocytes, neutrophile type develops promptly, and persists 
in most instances for from four to six weeks, ac- 
cording to Hartmann and Vaquez, 2 but occasionally for a longer 

1 " Practice of Medicine," Phila., 1898, p. 606. 

2 Compt. rend. Soc. biol., Paris, 1897, vol. iv. , p. 126. 



THE EFFECT ON THE BLOOD OF SPLENECTOMY. 273 



period. Counts of between 1 5 ,000 and 30,000 represent the grade 
of leucocytosis ordinarily found, although occasionally the increase 



Table XII. 

The Effect on the Blood of Splenectomy. 







<u 


e/i 


6 • 


8 


53 8 


<2 




£ 


globi 


>1 

0 
0 


V 

>> 


cytes 


ly 

cytes 


:iucle 
aphil 


ophil 


Notes. 


3 


0 
S 


is 


O 
3 


mall 
pho 


arge 
pho 


O 3 


.5 

0 






M 


H 




m 




>-< c 








6; 
u d 


5,200,000 


2, 200 


22 


5 


70 




Before operation. 
Megaloblasts and nor- 
moblasts found. 




65 


5,000,000 


24,0OO 
21,400 
23,800 
18,000 
18,000 


1 6 
3- u 


5- z 


93 


. 2 


2 days after operation. 

3 „ « 

t 

5 " " " 
8 « << 




45 


3,256,000 


24,000 


7-9 


8-5 


8t 
ot 


2.0 


11 " " " 

Myelocytes and mast 
cells found. No eryth- 
roblasts. 






4,496,000 


16,400 






76.8 




16 days after operation. 




45 


17,000 


7.8 


9 


6.2 


21 " << " 






3,984,000 












Myelocytes, . 2 per cent. 




4 U 


20,000 


9 


7-4 


82.2 


T A 
1.4 


27 days after operation. 


















No erythroblasts. 




40 


4,000,000 


15,000 


7-4 


82.8 


4 


37 days after operation. 




52-5 


4,672,000 


21 60O 


t r 4 


of 


73f 


2 


















Myelocytes found ; no 
erythroblasts. 








16,000 


51 


ioi 


79| 


3-5 


99 days after operation. 
















Erythrocytes normal. 


— 
22 


108 


4,850,000 


30,000 


8 


8 


83 


1 


Before operation. 




100 


4,7OO,O0O 


39,000 


5 


4 


9 l 


0 


7 days after operation. 




105 


3,630,000 


l8,000 


15 


6 


78 


1 


60 " " " 




63 


2,750,000 


20,000 


5 


10 


84 


1 


3 years " " 


3 3 


45 


1,634,000 


12,000 


16 


20 


61 


3 


14 days " " 




87 


2.460,000 


20,000 


18 


32 


49 


1 


27 " " " 




no 


4,530,000 


27,000 


18 


J 5 


66 


1 


33 " " . " 




100 


3,977,000 


8,000 


21 


11 


62 


6 


2 years and six months 
after operation. 


4 4 


63 


4,570,000 


8,000 










Before operation. 




64 


4,970,000 


30,000 










3 days after operation. 
6 " 




77 


5,l8o,000 


65,000 












66 


4,800,000 


17,5°° 










48 i* 




85 


4,353,000 


11,700 










4 months " " 




85 


3,300,000 


1 1,600 










5 years " " 



1 Warren : Annals of Surgery, 1901, vol. xxxiii., p. 513. 

2 Hartman and Vasquez : loc. cit. 

3 Ibid. 

4 Czerny, cited by Vulpius : Beitrage z. klin. Chir., 1894, vol. xi., p. 633. 

18 



DISEASES OF THE BLOOD. 



is far greater — 70,000 in a case cited by Czerny, 1 and 75,000 in 
one reported by Hartley. 2 After a number of months (usually 
some time during the second or third year after the operation), 
there is a moderate increase in the number of eosinophiles. In 
splenectomized guinea-pigs Kurloff 3 found during the first year 
after the operation a marked lymphocytosis, as high as 60 per 
cent, in some animals, together with a corresponding decrease in 
the number of granular cells, but with no alteration in the num- 
ber of large mononuclear leucocytes. Eosinophilia became ap- 
parent during the second year, and coincident with this change 
a decrease in the lymphocytes to their normal percentage took 
place. 

The above remarks concerning the differential changes affect- 
ing the leucocytes after splenectomy must be regarded as tenta- 
tive, in view of the fact that sufficient data bearing upon this 
question have not yet accumulated to justify more definite con- 
clusions. 

The table on page 273 shows the condition of the blood in the 
few recorded cases in which pre- and post-operative examinations 
have been carried out. 

It is to be remembered that, aside from the character of the 
splenic lesion, these important factors also determine the degree 
of the post-operative anemia and leucocytosis in this procedure : 
the grade of the preexisting anemia, the amount of hemorrhage 
during and following operation, and the patient's recuperative 
powers. All things being equal, the anemia is least marked and 
the blood regeneration most prompt in simple wandering spleen 
and in ague cake y while blood deterioration is more marked and 
regeneration slower in rupture of this organ. Splenectomy for 
spleno-medidlary leukemia is almost invariably followed by a pro- 
gressive anemia and leucocytosis, and in nearly all cases by death. 
But five recoveries after removal of the spleen in this disease 
have been reported up to the present time. 4 

1 Loc. cit. 

2 Med. News, 1898, vol. lxxii., p. 417. 

3 Cited by Ehrlich, loc. cit. 

4 Hagen : Archiv. f. klin. Chir., 1900, vol. v., p. 188. Also, Richardson, cited 
by Warren : loc. cit. 



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SECTION VI. 



THE ANEMIAS OF INFANCY AND CHILDHOOD. 



SECTION VI. 
THE ANEMIAS OF INFANCY AND CHILDHOOD. 



I. CHARACTERISTICS OF THE BLOOD IN CHILDREN. 

As a preliminary essential to the intelligent 
Fetal Blood, study of the various pathological conditions of 
the blood in children, it is necessary briefly to 
refer to certain points of difference in the composition of this tis- 
sue in the child and in the adult. In general terms, it may be 
stated that the younger the child the more unformed are the 
different elements of the blood and the nearer its composition 
resembles the blood of the fetus. 

In fetal blood the specific gravity, both of the whole blood and 
of the serum, is lower than in the adult, and coagulation is very 
slow. The erythrocytes vary greatly in size and in shape, and 
are deficient in hemoglobin, which is loosely attached to these 
cells, and hence becomes readily dissolved out. 

Until about the seventh month of intra-uterine life normo- 
blasts constitute the predominating variety of erythrocytes, after 
which period they rapidly diminish in number, until at full term 
few, if any, nucleated red corpuscles are found in the blood. Of 
the different varieties of leucocytes, the mononuclear forms are 
present in a proportion relatively excessive to the other varieties ; 
before the seventh month this lymphocytosis is due to a high 
relative percentage of large lymphocytes, but after this period 
the proportion of small lymphocytes increases, until finally 
the latter type of cells predominates. The percentage of 
eosinophiles reaches its maximum at the seventh month, gradu- 
ally becoming less and less as the end of the intra-uterine life 
approaches. 

We find, therefore, that in the fetus the blood is characterized 
chiefly by the presence of large numbers of normoblasts, by a 
high relative proportion of mononuclear leucocytes, and by a de- 
ficiency of hemoglobin. The closer an infant's blood resembles 
this picture, the "younger" in point of development is such 
blood considered, and the more strongly is it said to revert to a 
"young " or " embryonal " type. 



28o THE ANEMIAS OF INFANCY AND CHILDHOOD. 

At birth, the blood of the full-term infant is of 

The Blood higher specific gravity, and richer in hemoglobin 
at Birth. and in corpuscular elements than that of the older 
child or of the adult. 

The specific gravity of the blood of the average healthy infant 
at the time of birth and during the first few weeks of life is, ap- 
proximately, 1066. For normal children the average, which is 
reached by the beginning of the second year, varies from 1050 to 
1058, being slightly higher in boys than in girls. 

The maximum amount of hemoglobin is found at birth, the per- 
centage at this time ranging from 100 to 104, according to the 
investigations of Hammerschlag. 1 After birth the amount of 
hemoglobin immediately begins to diminish, the minimum, which 
may be as low as 55 or 60 per cent., being attained by the end 
of the third week of life. It remains at or about this minimum 
for a variable period of time, sometimes for as long as six months, 
and then gradually begins to increase. 

At birth, the number of erythrocytes in the peripheral blood is 
decidedly higher than normal, counts of between 5,500,000 and 
6,000,000 cells per cubic millimeter being found at this time, the 
highest figures being observed in those cases in which ligation of 
the umbilical cord has been delayed. During the first twenty- 
four hours of extra-uterine life this polycythemia becomes still 
more marked, so that the number of corpuscles per cubic milli- 
meter may reach a maximum of from 7,000,000 to 8,000,000, 
and sometimes more, by the end of the first day. Beginning with 
the second day, a gradual diminution in the number of these cells 
is noticed, and the normal 5,000,000 per cubic millimeter is reached 
by the end of the first week or ten days. Hayem 2 emphasizes the 
fact that the fluctuations in the number of erythrocytes during the 
early days of life stand in inverse ratio to the variations in the 
weight of the child, the maximum number being found at the 
time of the infant's minimum weight, while as the child begins to 
gain in weight the count decreases. SchifT 3 is inclined to attrib- 
ute these fluctuations to the amount of liquids in the body, the 
result of feeding, showing that in fasting children the counts are 
always higher than in those fed at frequent intervals. 

Whatever may be the exact manner of their production, it is 
evident that these fluctuations are to be regarded as purely physio- 
logical in character, depending upon concentration and dilution of 
the blood, rather than as an expression of involvement of the 
blood-making organs. 

iCentralbl. f. klin. Med., 1891, vol. xii., p. 825. 
2"Du Sang," etc., Paris, 1889. 
3 Zeitschr. f. Heilk., 1890, vol. xi., p. 17. 



CHARACTERISTICS OF THE BLOOD IN CHILDREN. 28 1 



The erythrocytes vary greatly in size during the first few days 
of post-natal life, the diameter of some cells being as small as 
3.25 fi, and of others as large as 10.25 fi. Many observers have 
noticed that the small-sized cells, as a rule, predominate. 

Nucleated erythrocytes of the normoblastic type may or may 
not be present in the blood of new-born infants ; they are com- 
monly found in large numbers in the prematurely born child, and 
also occur less numerously in many fully developed babies, not- 
withstanding views to the contrary expressed by some observers, 
notably by Hayem 1 and by Fischl. 2 In most cases normoblasts 
disappear from the blood after the first few days of life, and their 
presence after the sixth month should always be regarded as pa- 
thological. 

The number of leucocytes at birth averages about 20,000 per 
cubic millimeter, the normal average for young infants, 15,000 
per cubic millimeter, being reached by the end of the first week, 
after numerical fluctuations similar to those affecting the erythro- 
cytes. From the second or third week until the sixth month, a 
count from 10,000 to 14,000 may be regarded as normal, while for 
the child of one year of age the average is about 10,000. By the 
sixth year the number of leucocytes falls to the number normal 
for the adult, 7,500 per cubic millimeter. The following excel- 
lent table from Rotch, 3 shows these average counts of erythrocytes 
and leucocytes in children from birth until the sixth year of age : 



Age. 


Erythrocytes. 


Leucocytes. 


At birth. 


5,900,000 


21,000 (26,000 to 36,000 
after first feeding). 




End of 1st day. 


7,000,000 to S, 000, 000 


24,000 


" 2d " 


Generally increased. 


30,000 


" 4th " 


6,000,000 


20,000 


» 7 th « 


5,000,000 


15,000 


loth day. 




10.000 to 14,000 


1 2th to 1 8th day. 




12.000 


1st year. 




10,000 


6th year and upwards. 




7,500 



The influence of the initial feeding in infants produces a marked 
leucocytosis, the increase amounting to from 5,000 to 15,000 
cells per cubic millimeter, as shown by the above table. It is 
probable that the habitual leucocytosis of early childhood is 
largely referable to a more or less continuous digestion leucocy- 
tosis. (For a further discussion of this question see " Digestion 
Leucocytosis," page 179.) 

1 Loc. cit. 

2 Zeitschr. f. Heilk., 1892, vol. xiii., p. 277. 

3 "Pediatrics,' 7 etc., Phila., 1896, p. 342. 



282 



THE ANEMIAS OF INFANCY AND CHILDHOOD. 



The blood of infants and of young children differs greatly from 
that of the adult in the relative proportions of the different forms 
of leucocytes, these qualitative differences becoming less and less 
apparent as the child grows older, and not usually persisting 
beyond the tenth year. In general terms, it may be said that 
these dissimilarities are striking in relation to the youth of the 
child. Compared to the adult, a differential count of the leuco- 
cytes in the child shows that the relative percentage of lympho- 
cytes is more than twice as great, and of polynuclear neutrophiles 
one-half as great, while the proportion of eosinophiles is fre- 
quently much higher. In the following table, based upon data 
given by Gundobin, 1 these points of difference are contrasted : 

Forms of Leucocytes. Infants. Adults. 

Small lymphocytes. 50 to 70 per cent. 20 to 30 per cent. 
Large lymphocytes, 
and transitional 

forms. 6 " 14 " 4 " 8 " 

Polynuclear neutro- 
philes. 28 " 40 " 60 " 75 " 

Eosinophiles. 0.5 " 10 " 0.5 " 5 " 

It is important to take into account these differences, in mak- 
ing blood examinations in children, in whom we must expect to 
find percentages of lymphocytes which in the adult would be 
regarded as abnormally high. 

Leucocytosis in children is of extremely common occurrence, 
often arising from causes of the most trivial character, and de- 
veloping to a greater degree and with much more rapidity than 
in the adult. It is therefore to be regarded with less significance 
than when it occurs in the mature. Usually the polynuclear cells 
are chiefly involved in the increase, but the inclination of the 
blood of children to revert to the embryonic type appears to 
cause, in many cases, a disproportionate increase of lymphocytes 
in relation to the other forms, this peculiarity being especially 
true of the various pathological leucocytoses. Physiological leu- 
cocytosis in children usually affects chiefly the polynuclear neu- 
trophil cells. 

II. ANEMIA IN CHILDREN. 

Children, as a class, are peculiarly susceptible 
Frequency, to anemia, for they appear to lack resisting pow- 
ers against the influence of causes tending to pro- 
duce pathological alterations in the blood. Thus, it is found that 
the same factors which in the adult have little or no effect upon 

1 Jahrb. f. Kinderheilk., 1893, vol. xxxv., p. 187. 



ANEMIA IN CHILDREN. 



283 



the blood are capable of producing profound alterations in its 
composition in the child. Severe anemias may arise in children 
from apparently the most trivial sorts of causes ; slight hemor- 
rhage from the navel, for instance, may light up an anemia of an 
intensity out of all proportion to the actual, amount of the blood 
loss, while minor lesions of the gastro-intestinal tract are com- 
monly associated with blood deterioration of a severe type. 

It is a notable fact that in anemic children a 
General predominant tendency exists toward a reversion 

Character- of the blood to a less mature histological type, 
istics. such as that found in the blood of the fetus. 

Thus, in children, anemia of a type which in the 
adult is unattended by qualitative changes in the corpuscles is 
commonly associated with the presence of large numbers of 
nucleated erythrocytes, these cells being far more numerous than 
the severity of the anemia would seem to warrant ; poikilocytosis, 
and deformities in the size of the corpuscles also occur with far 
greater frequency than in the adult. Regeneration of the blood 
takes place slowly. The oligochromemia is relatively greater than 
the oligocythemia in most anemias of children, this being due 
probably to the fact that the hemoglobin is peculiarly prone to 
separate from the corpuscular stroma. Owing to this fact low 
color indices, as in chlorosis, are common, irrespective of the 
degree of corpuscular diminution. 

Myelocytes are commonly found in the blood in all the anemias 
of children ; they are present in larger relative percentages and in 
less severe pathological conditions than in the adult. 

Leucocytosis, often lymphocytosis, and enlargement of the spleen 
are frequently associated with all forms of anemia in the young ; 
and although these conditions are likely to coexist, this is by no 
means the invariable rule. Splenic enlargement is especially 
common in the anemias due to syphilis, rachitis, tuberculosis, 
gastro-intestinal disease, malaria, and septic infection. 

To epitomize, in the anemias of infancy and childhood the follow- 
ing prominent features in the blood are found : fa) the frequency 
of a low color index ; {&) the common occurrence of erythro- 
blasts, and of deformities affecting the shape and size of the 
erythrocytes ; (V) a tendency toward leucocytosis and splenic 
enlargement, and (d) the frequency of myelocytes. 

It is owing to these peculiarities that the clas- 

Classifica- sification of the anemias of children is such a dif- 
tion. ficult matter. The older classifications, based 
upon the nature of the causal factors of the an- 
emia and upon the presence or absence of enlargement of the 



284 THE ANEMIAS OF INFANCY AND CHILDHOOD. 



spleen, have failed in many respects to prove adequate, so that it 
becomes necessaiy to adopt a simpler and more comprehensive 
division from which no exceptions need be made in the individual 
case. Such a classification has recently been suggested by 
Morse. 1 This author assuming, and rightly so, that chlorosis is 
a condition wholly foreign to infantile life, and that the disease de- 
scribed by von Jaksch as "Anemia infantum pseudoleukemica " 
does not represent a distinct clinical entity, proposes this excellent 
classification, slightly modified from that of Monti : 

Primary Anemia. Pernicious anemia. 

Leukemia. 

Secondary Anemia. Mild anemia. 

Mild anemia with leucocytosis. 
Severe anemia. 

Severe anemia with leucocytosis. 

Pernicious anemia is rare in the young, and 
Primary likely to be mistaken for other forms of severe an- 
Anemia. emia secondary to various conditions. It is prob- 
able that many of the reported cases of Biermer's 
anemia in infants were in reality examples of severe secondary 
anemia. The apparent tendency of pernicious anemia in children 
to become transformed into leukemia is doubtless more fanciful 
than real, a remark which is equally true of those few reported 
instances of the conversion of leukemia into pernicious anemia. 
In the first case, the erroneous impression may arise from such 
evidence as marked enlargement of the spleen associated with a 
high leucocytosis ; in the second, a temporary disappearance of 
the myelogenous blood-picture plus an aggravation of the exist- 
ing anemia may be sufficient to convey the false impression. It 
must be admitted that these atypical blood changes, so common 
in young children, are highly confusing and difficult to interpret 
without the closest observation and the correlation of other clin- 
ical signs. 

Infantile pernicious anemia is characterized by the same blood 
changes that are found in the adult, in so far as striking oligocy- 
themia, and nucleation and deformities of the erythrocytes are 
concerned, but the blood often fails to show the high color 
index and the prevalence of megaloblasts and of megalocytes 
which must be considered diagnostic of this disease in the adult. 

Leukemia in children is uncommon, but instances have been 
reported during all stages of infancy and childhood, even in the 

1 Archives of Pediatrics, 1898, vol. xv., p. 815. 



PRIMARY ANEMIA. 



285 



new-born. Acute forms of the disease are most frequently met 
with, the great majority of cases, according to Holt, 1 proving 
fatal within a year from the appearance of the first symptoms, 
while in many the disease runs its course in a few weeks. Male 
children are more commonly leukemic than females. Conditions 
such as rachitis, syphilis, and malarial fever have been regarded by 
some authors as possessing a certain amount of importance as 
etiological factors, but in the vast majority of cases the cause of 
the disease is entirely obscure. 

Of the several collected reports of leukemia in children, the 
two articles of Morse, giving a total of 27 cases, are by far the 
most valuable. In his first communication 2 20 cases were re- 
corded, including one of his own, tabulated below, but of this 
series the diagnosis in the great majority of instances being based 
either upon clinical symptoms or upon inadequate examination 
of the blood, the reporter is led to remark that "It is highly 
probable that not more than half, perhaps not more than a third 
of these were really cases of leukemia." In Morse's second 
article, 3 which deals with the acute form of the disease, seven 
cases, again including one of his own, also recorded below, are 
reported. 

Although the literature of pediatrics is fairly rich in alleged 
examples of leukemia in children, the cases, with but a few ex- 
ceptions, are reported in such an unsatisfactory manner that they 
cannot be regarded without reserve as typical. Those reported 
prior to the publication of Morse's first article, in 1894, must all 
be open to criticism, owing to the general disregard for differen- 
tial counts shown by the various authors, and, strangely enough, 
this criticism must hold true for many cases recorded during the 
past seven years. The author has been able to collect ten cases 
(Table XIII.), in all of which the differential count of leucocytes 
leaves no doubt as to the precise character of the disease. 

In addition to the above cases several others have been reported, 
in which the differential count of leucocytes has either been faultily 
made or entirely neglected. Thus, Pollman 4 believes that he has 
seen a case of spleno-medullary leukemia in a new-born infant, 
the count on the fourteenth day after birth being 2,500,000 ery- 
throcytes and 312,500 leucocytes per cubic millimeter. The 
latter consisted chiefly of " large mononucleated cells, with large, 
distinct nuclei, and an abundance of protoplasm." Nucleated 
forms of erythrocytes were not found. Cassel, 5 in addition to 

1 "The Diseases of Infancy and Childhood," N. Y., 1897, p. 806. 

2 Boston Med. & Surg. Journ., 1894, vol. cxxxi., p. 133. 

3 Archives of Pediatrics, 1898, vol. xv., p. 330. 

4 Miinch. med. Woch., 1898, vol. xlv., p. 44. 
5 Berl. klin. Woch., 1898, vol. xxxv., p. 76. 



286 



THE ANEMIAS OF INFANCY AND CHILDHOOD. 



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SECONDARY ANEMIA. 



287 



his own case, tabulated above, has collected four other cases oc- 
curring in children under fourteen years of age. 

Theodor 1 has collected from German literature six cases of acute 
leukemia in children between the ages of two-and-one-half and 
eight years of age, and also reports one of his own, apparently 
of the lymphatic form, in a boy of four years. No actual numer- 
ical estimates of the corpuscles are given, but the proportion of 
leucocytes to erythrocytes is stated to vary from 1:9 to 1 : 3. 
The differential count of leucocytes is also very inexact. The 
greater percentage apparently consisted of lymphocytes ; myelo- 
cytes were fairly numerous, many of them containing mitotic fig- 
ures, and normoblasts and megaloblasts were present in large 
numbers. Charon and Gratea 2 report a case of spleno-medul- 
lary leukemia in a child of eight years, the percentage of hemo- 
globin being 39, the erythrocyte count 880,000, and the leuco- 
cyte count 305,000. 

In the above classification of the secondary 

Secondary anemias, under the heading of mild anemia are 
Anemia. included those cases characterized by trifling re- 
duction in the hemoglobin percentage and num- 
ber of erythrocytes, and by an absence of histological alterations 
in these cells. The color index in these cases is usually 1.00, or 
slightly below, uncommonly falling to a low figure. 

The term severe anemia includes cases having marked diminu- 
tion of hemoglobin and erythrocytes, associated with deformities 
of shape and of size and nucleation of these cells. The hemo- 
globin loss is especially marked, often being only one-quarter or 
one -third of normal, and the color index is low. 

Anemias with leucocytosis, whether of mild or of severe type, 
are generally marked by a greater degree of hemoglobin and 
corpuscular decrease than anemias without leucocytosis. The 
leucocytosis is moderate in the milder forms, but in severe cases 
the increase in the number of leucocytes often appears to be pro- 
gressive, and the relative number of leucocytes to erythrocytes 
occasionally attains the proportion 1 to 1 00. 

Histological changes in the erythrocytes are more striking in 
grave anemias with leucocytosis than in grave anemias pure and 
simple. This is especially true of the changes relating to nuclea- 
tion of the cells, normoblasts and atypical forms being very nu- 
merous in the former class. Typical megaloblasts are occasion- 
ally found, but these cells are not common in the blood of chil- 
dren, even in the most severe anemias. 

1 Archiv. f. Kinderheilk., 1897, vol. xxii., p. 47. 

2 Bull. Soc. roy. sc. med. et nat., Bruxelles, 1896, vol. liv., p. 63. 



288 



THE ANEMIAS OF INFANCY AND CHILDHOOD. 



Regarding the etiological factors of these secondary anemias, 
the following groups of causes are given by Monti i 1 



Syphilis, either congenital or acquired, is responsible for a large 
proportion of the cases of anemia in children, especially those of a 
severe type, associated with enlargement of the spleen, and often 
also with enlargement of the lymphatic glands. The hemoglo- 
bin loss is in most instances disproportionately greater than the 
corpuscular decrease, so that low color indices are especially 
common in this disease — the misnamed " chlorosis " of syphilis. 
Deformities and nucleation of the erythrocytes are common 
in the severer types, and in such forms polychromatophilic 
changes and excessive decrease in the number of erythrocytes 
are usually present. A leucocyte increase is present in the sec- 
ondary stage, and is usually associated with the grave anemia 
of this disease ; the relative precentage of lymphocytes is in- 
creased, and of polymorphous forms decreased ; and small num- 
bers of myelocytes are common. From the writer's experience, 
in the average case of moderate severity the percentage of hemo- 
globin varies from about 40 to 50, the erythrocytes are reduced 
to about 3,000,000 to 3,500,000 per cubic millimeter, and the 
leucocyte count is in the neighborhood of 20,000 ; but in severe 
cases the erythrocytes may be reduced to 1,000,000, and the leu- 
cocytes increased to 50,000 or more. As in the adult, Justus' 
test proves of value in the diagnosis of many anomalous cases. 

In rachitis there is usually well-marked anemia, commonly 
accompanied by decided enlargement of the spleen, such cases 
usually having most decided blood changes. The hemoglobin 
percentage is usually relatively lower than the percentage of 
corpuscles, so that low color indices prevail ; but in the indi- 
vidual case neither the oligochromemia nor the oligocythemia 
are usually as marked as in syphilis. In severe cases, deformed 
and nucleated erythrocytes, and a small percentage of myelo- 
cytes are commonly found. The number of leucocytes is as a 

1 Wien. med. Woch., 1894, vol. xliv., pp. 401, 464, 516, 560, and 613. 



1. Congenital. 




2. Acquired. 

General. 



Hemorrhagic. 



From navel, from circumcision, etc. 
Purpuric diseases. 

Malnutrition, improper hygiene, etc. 
Syphilis, rachitis, and tuberculosis. 
Gastro-intestinal diseases. 
Visceral diseases. 
Febrile diseases. 
Septic infections. 
Nephritides. 
Malignant growths. 



SECONDARY ANEMIA. 



289 



rule moderately increased, and relatively high percentages of 
lymphocytes are common. 

Uncomplicated tuberculosis, due to pure infections with the 
tubercle bacillus, produces an anemia which varies in degree 
with the severity of the constitutional effects of the disease. The 
hemoglobin and erythrocytes are usually but slightly decreased, 
the former suffering a relatively greater loss, and the number of 
leucocytes does not rise above normal. If to the tuberculous 
process a septic infection is superadded, the anemia becomes 
severer, and leucocytosis, involving the polymorphous forms of 
leucocytes, occurs. Splenic enlargement is common, and some- 
times marked. The anemia of tuberculosis is in no way referable 
to the infection itself, but depends upon the drain on the albumi- 
noid materials of the blood due to the presence of a long-con- 
tinued cachexia. 

G astro-intestinal diseases, especially those of chronic character, 
cause most marked anemia. Chronic inflammations of the intes- 
tines strikingly affect the blood, the percentage of hemoglobin 
frequently falling to one-quarter of normal or even less, and the 
number of erythrocytes being decreased to one-half of normal or 
less. Deformities affecting the shape and size of the erythrocytes, 
and nucleation of these cells are of frequent occurrence. A leu- 
cocyte increase, involving in many instances the lymphocytes, 
is usually present, and small percentages of myelocytes have 
been observed. Splenic enlargement is frequently a conspicu- 
ous clinical sign. It should be remembered that in acute forms 
of gastro-intestinal disorders, in which profuse diarrhea and vom- 
iting occur, concentration of the blood takes place, causing tem- 
porary polycythemia which may for a time hide the real degree 
of the blood deterioration. The anemias found in this class of 
diseases are apparently to a large extent autointoxicative in char- 
acter, depending to a less degree upon insufficient nutrition. 

In enteric fever the blood-picture does not differ essentially 
from that seen in the adult suffering from this affection, absence 
of leucocytosis or leucopenia with progressive anemia being 
found with great constancy. In 12 cases recently studied by 
Stengel and White 1 the hemoglobin ranged from 68 to 83 per 
cent.,the erythrocytes from 3,320,000 to 5,200,000, and the leu- 
cocytes (in uncomplicated cases) from 3,800 to 12,320. Poly- 
nuclear leucocytosis was observed in 3 cases as the result of in- 
flammatory complications. Two uncomplicated cases showed 
fractional percentages of myelocytes, but there were no other dif- 
ferential changes of any consequence. The writer has found that 

1 Archives of Pediatrics, 1901, vol. xviii., pp. 241 and 321. 

19 



29O THE ANEMIAS OF INFANCY AND CHILDHOOD. 



the alkalinity of the blood varies within wide limits in infantile 
typhoid, tests, by Engel's method, in 6 consecutive cases showing 
a range of from 373 to 692 mgrms. NaOH. The rapidity of co- 
agulation also was found to vary greatly, clotting taking place in 
as short a time as 37 seconds in one instance, and not occurring 
for 4 minutes and 35 seconds in another. Morse 1 concludes that 
the serum test appears earlier, is less marked, and persists for a 
shorter period in children than in adults. In a nursling it should 
be remembered that a positive reaction may be of uncertain value, 
for the reason that the agglutinating power may be transmitted 
from mother to child through the milk, both during the active 
stages of the disease and also during and after convalescence. 

Under the title "Anemia infantum pseudoleukemia" von 
Jaksch 2 has described a condition which he regards as a form of 
primary anemia peculiar to the young child. The blood changes, 
none of which are characteristic of the disease in question, as this 
author admits, consist of (a) marked oligocythemia and oligo- 
chromemia, (p) extensive and persistent leucocyte increase, and 
(c) striking structural alterations in the erythrocytes. Associated 
with these changes in the blood, and of equal importance in diag- 
nosing the disease, constant enlargement of the spleen, and, less 
commonly, enlargement of the liver are found. 

The number of erythrocytes is greatly decreased, usually to 
from 2,000,000 to 3,000,000 per cubic millimeter, but sometimes 
falling to 1,000,000 or even to a lower figure, as in one of von 
Jaksch' s cases, in which the count was only 820,000. The 
hemoglobin loss is also great, relatively more so than the cor- 
puscular decrease. 

The leucocyte gain is decided, averaging, in the majority of 
cases, from 30,000 to 50,000 corpuscles per cubic millimeter, and 
in some instances exceeding 100,000. In some cases the in- 
crease involves principally the polynuclear neutrophiles, while 
in others the lymphocytes are the cells chiefly affected. The 
cells show a most striking dissimilarity of form and of size, and 
a highly confusing variety of forms atypical in size, shape, and nu- 
clear morphology is encountered. This " polymorphous" state 
of the leucocytes is a point insisted upon by von Jaksch in his 
description of the condition. The number of eosinophiles varies 
within wide limits, the percentage of these cells being normal, 
decreased, or increased. Small percentages of myelocytes have 
been observed. 

The histological changes affecting the erythrocytes consist in 

"Archives of Pediatrics, 1901, vol. xviii., p. 338. 
2 Wien. klin. VVoch., 1889, vol. ii., p. 435. 



SECONDARY ANEMIA. 



2 9 I 



marked poikilocytosis, deformities of size, loss of color, and nu- 
cleation. Poikilocytes, megalocytes, and microcytes occur in 
large numbers, and the pallor of most of the corpuscles is ex- 
treme. Normoblasts are the most common form of erythro- 
blasts observed, but in some instances the occurrence of atypical 
forms, small and large, and of megaloblasts has been noted. 
Karyokinetic changes in these cells are not uncommonly seen, 
and polychromatophilia is said to be of frequent occurrence. 

The spleen is enlarged in all cases, sometimes moderately, but 
often very greatly, so that the organ extends far below the cos- 
tal margin, and occupies the entire upper left part of the abdomi- 
nal cavity. The spleen is extremely indurated, and may show 
capsular thickening from perisplenitis. The increase in the size 
of the organ is due to a hyperplasia. Increase in the size of the 
liver is not constant in all cases, and when present does not 
reach a size corresponding to that of the spleen, as is the case in 
leukemia ; the lower border of the liver is not rounded, but dis- 
tinctly sharp. In a certain proportion of cases the lymphatic 
glands are slightly enlarged, but never to any notable extent. 
Changes in the bone marrow, common to any severe anemia, 
have been observed in some cases. 

The disease occurs most frequently in infants between the ages 
of seven and twelve months, and is rarely met with in children 
over four years old. By some writers it is supposed to be slightly 
more common in children of the male sex. 

In many cases a previous history of rachitis, syphilis, or long- 
standing gastro-intestinal disease is obtained, although von Jaksch 
denies the existence of these etiological factors in his cases. 

The onset of the symptoms is slow and insidious, and the pal- 
lor of the skin, blanching of the mucous membranes, and other 
signs of anemia slowly develop, with the gradual enlargement of 
the spleen, until these clinical manifestations become marked. 
In all cases there is excessive loss of strength, and in a great 
many a high degree of emaciation. 

Von Jaksch's disease, if untreated, tends to pursue a progres- 
sively grave course, ending fatally ; but, under suitable treat- 
ment, in the majority of cases the splenic tumor decreases in 
size, the leucocytosis disappears, and the hemoglobin and eryth- 
rocytes return to normal. 

Pseudoleukemic anemia of infants is not generally considered 
as a separate clinical entity, but is regarded rather as a form of 
severe secondary anemia associated with marked leucocytosis and 
splenic enlargement. It may be due to a number of different 
causes, the most prominent among which are syphilis, rachitis, 



292 



THE ANEMIAS OF INFANCY AND CHILDHOOD. 



and chronic gastro-intestinal disease. The conflicting reports of 
different authors concerning this disease, and the incompleteness 
with which the leucocytes have been studied in many instances, 
render it probable that in some of the reported cases pernicious 
anemia and leukemia have masqueraded as typical examples of 
the condition described by von Jaksch. 

Bacteriemia, generally referable to pre-agonal infections, appears 
to occur with great frequency in the young child during the course 
of many acute diseases. Delestre's recent studies 1 of general 
blood infections in children tend to show that infants born before 
full term are peculiarly susceptible to this condition. Using care- 
ful technique, this author examined 40 children, ranging in age 
from a few days to four years, all of whom were believed to be 
suffering from infections which bade fair to end fatally within a 
few days, at the latest. Of the 32 fatal cases of this series, bacteria 
were found in the blood during life in 14, while of the 8 who re- 
covered, but one gave a positive result. The bacterium found 
with greatest frequency was the streptococcus, while staphylococci, 
pneumococci, colon bacilli, and influenza bacilli were isolated more 
rarely. It was furthermore shown that premature babies seemed 
especially susceptible to streptococcus and colon infections, and 
that nursing infants several months old were more prone to suffer 
from the effects of the staphylococcus. 

The blood changes occurring in pertussis, pneumonia, diphtheria, 
scarlet fever, measles, and other infectious diseases of childhood 
are considered in Section VII. 

1 Annal. degynecol. et d' obstet. , 1901, vol. lv., p. 51. 



SECTION VII. 



GENERAL HEMATOLOGY. 



SECTION VII. 



GENERAL HEMATOLOGY. 



I. ABSCESS. 

The rate of coagulation is, as a rule, somewhat 
General slower than normal. Hyperinosis is conspicuous, 
Features, and under the microscope the fibrin network ap- 
pears abnormally dense and thick. The iodine 
reaction may be detected in the dried blood film by the method 
described in a previous section. (See page 174.) These remarks, 
as well as those which follow, do not apply to purely tuberculous or 
"cold" abscesses, the effects of which are referred to elsewhere. 

If the absorption of toxic material from an ab- 
Hemoglobin scess is great enough to produce a systemic effect 
and upon the patient, anemia of an intensity parallel 

Erythrocytes, to the severity of the poisoning sooner or later 
develops. This fact is sufficient to explain why 
the grades of anemia in purulent conditions vary within such wide 
limits. The size and the site of the abscess do not appear pri- 
marily to determine the degree of the associated blood changes, 
although, other circumstances being equal, a large, deep-seated 
collection of pus is likely to have a more harmful effect than one 
of small size and superficial situation. Chronicity of the lesion 
seems to go hand in hand with an increase in the blood deterio- 
ration — few persons harboring pus for a protracted period fail to 
show decided signs of anemia. 

In many cases, especially the acute, the only noticeable change 
is a moderate oligochromemia, but in chronic cases different de- 
grees of ordinary secondary anemia are commonly encountered, 
amounting in an exceptional instance to a reduction of hemo- 
globin to as low as 20 or 30 per cent, of the normal standard, and 
to an erythrocyte decrease to between 2,000,000 and 3,000,000 
cells to the cubic millimeter. Such profound losses are of course 
unusual, for in the majority of patients with anemia the hemo- 
globin is above 50, and the corpuscles above 60 per cent, of nor- 
mal. The average color index for 76 German Hospital cases, 
listed below, was 0.73. The condition of the hemoglobin and 
erythrocytes in these patients is shown by the following summary : 



296 



GENERAL HEMATOLOGY. 



/. Superficial abscess of 
hand, arm, foot, and abdom- 
inal wall ; palmar, axillary, 
cervical, cerebral, hepatic, 
renal, periurethral, and 

ischio-rectal abscess; empyema II. Pelvic abscess ; ovar- 
of gall-bladder. ian abscess ; Pyosalpinx. 

Hemoglobin Percentage. No. of Cases. No. of Cases. 

From 90 to 100 1 o 

" 80 to 90 3 1 

" 70 to 80 7 5 

" 60 to 70 7 4 

" 50 to 60 6 9 

" 40 to 50 10 9 

" 3° to 40 5 3 

" 20 to 30 3 3 



Average : 
Maximum 
Minimum 



57.0 per cent. 
95.0 « 
20.0 " 



54.0 per cent. 
82.0 " 



Erythrocytes per cb. mm. 

Above 5,000,000 5 

From 4,000,000 to 5,000,000 14 

" 3,000,000 to 4,000,000 18 

" 2,000,000 to 3,000,000 3 

" 1,000,000 to 2,000,000 2 



Average : 
Maximum : 
Minimum : 



3,881,190 per cb. mm. 
5,250,000 " 
1,500,000 " " 



o 
12 
18 

3 
1 



3*634,823 per cb. 
4,730,000 ' 



mm. 



1,310,000 



( i 



If marked anemia exists, a variable grade of cell deformity, 
atypical staining, and nucleation is also to be observed. If the 
latter change is evident, it will be found that the great majority, if 
not all, of the nucleated corpuscles belong to the normoblastic class. 

Practically the same influences governing the 

Leucocytes, behavior of the leucocytes in most other infec- 
tions also determine their increase and decrease 
in abscess. Thus, in both trivial and in extensive pus foci the 
number of leucocytes may be normal, or even subnormal ; in the 
former instance because systemic reaction is not provoked, and 
in the latter because it is overpowered. Leucocytosis may also 
be absent in case toxic absorption is impossible, owing to the 
complete walling-ofif of the abscess. In all other instances 
save these, a definite and usually well-marked leucocytosis 
occurs, amounting on the average to a count of about twice 
the mean normal standard, but frequently greatly exceeding 



ABSCESS. 



297 



this figure in the individual case. The size of the primary 
abscess cannot be estimated by the height of the leucocytosis, 
but a tendency of the pus to extend is almost always accom- 
panied by a distinct increase in the number of cells in excess of 
the figure originally estimated. Complete evacuation of the ab- 
scess is soon followed by a disappearance of the leucocytosis, but 
so long as the pus remains ineffectually drained the high count 
tends to persist. 

The frequency of leucocytosis and the range of the counts in 
various forms of abscess are shown by the following summary of 
the cases already mentioned : 

I. Superficial abscess of 
hand, arm, foot, and abdom- 
inal wall ; palmar , axillary, 
cervical, cerebral, hepatic, 
renal, periurethral, and 

ischio-recial abscess ; em- II. Pelvic abscess ; ovarian 
pyema of gall-bladder . abscess ; pyosalpinx. 



Leucocytes per cb. mm. 




No. 


of Cases. 




No. of Cases. 


Above 35, ceo 








0 




3 


From 30, coo to 


35> oco 






O 




0 


tl 25,000 to 


30,000 






0 




1 


" 20,000 to 


2 5 , 0 c 0 






7 




3 


" 1 5, coo to 


20, coo 






9 




8 


" io,oco to 


15,000 






20 




10 


" 8,000 to 


10,000 






4 




4 


" 6,000 to 


8,000 






1 




4 


" 4, coo to 


6,000 






1 




0 


Below 4.000 








0 




. 1 


Average : 




14, 


388 


per cb. mm. 


15 


54S per cb. 


Maximum 




24, 


ceo 


it tt 


41 


000 " " 


Minimum 




4, 


8co 


a ti 




- - n i t a 



A polynuclear neutrophile gain accounts for the increase when 
leucocytosis is present, and, rarely, this differential change may 
be found without any increase in the total number of leucocytes. 
A few myelocytes may occasionally be observed in cases having 
a decided anemia or a high leucocytosis. 

The presence of leucocytosis, especially if as- 

Diagnosis. sociated with hyperinosis and a positive iodine 
reaction, is suggestive of abscess rather than of 
other lesions, such as aneurisms, gummata i hematomata, and benign 
neoplasms. An absence of one or all of these signs, on the other 
hand, is not sufficient to exclude pus. The distinctions, as shown 
by the blood, between pyogenic and tuberculous abscesses and 
malignant disease are considered under the last-named conditions. 



298 



GENERAL HEMATOLOGY. 



II. ACROMEGALY. 

The following counts illustrate the blood changes found in two 
cases of this disease, the first showing practically normal blood, 
except for a moderate relative lymphocytosis and an absence of 
eosinophiles, and the second simply a well-marked secondary 
anemia, with a high color index. 



Hemoglobin. 
Erythrocytes. 
Color index. 

Leucocytes. 

Small lymphocytes. 
Large lymphocytes. 
Polynuclear neutrophiles. 
Eosinophiles. 
Basophiles. 
Myelocytes. 



Case I. 
86 per cent. 
4,620,000 per cb. mm. 
0-93 

8,000 per cb. mm. 
31.7 per cent. 

2.1 

66.2 
0.0 
0.0 
0.0 



Case II. 
60 per cent. 
2,880,000 per cb. mm. 
1.04 

4,890 per cb. mm. 

21.0 per cent. 

7.0 
71.0 

1.0 

0.0 

0.0 



The erythrocytes showed moderate deformities of size and 
shape in the anemic case, but neither signs of nucleation nor of 
basophilic stroma degeneration were observed. Coagulation, 
fibrin formation, and the number of plaques were apparently 
normal. 

III. ACTINOMYCOSIS. 

Anemia, marked by a disproportionately great hemoglobin de- 
crease, is generally found, and leucocytosis appears to be a con- 
stant feature of the blood-picture, judging from the small number 
of reports available. It is probable that the grade of both the 
anemia and the leucocytosis depends largely upon the amount 
of septic absorption originating from the lesion. 

IV. ACUTE YELLOW ATROPHY OF THE LIVER. 

Malignant jaundice appears to be associated with a moderate 
polycythemia, so far as can be determined by the limited number 
of blood counts made in this disease up to the present time. 
The leucocytes are moderately increased in number, but show no 
peculiar differential changes, so far as is known. In two cases, 
reported by Grawitz, 1 and by Cabot, 1 respectively, the counts of 
erythrocytes were 5,150,000 and 5,520,000, and the number of 
leucocytes 12,000 and 16,000 per cubic millimeter. Bacterio- 
logical examination of the blood has thrown no definite light 
upon the nature of this apparently infectious process. In many 
cases hemoglobinemia and lipacidemia have been detected. 



1 Loc. cit. 



addison's disease. 



299 



V. ADDISON'S DISEASE. 

Moderate anemia is commonly, and decided 
Hemoglobin anemia occasionally, associated with this condi- 
and tion, although the prime importance of this 

Erythrocytes, symptom insisted upon by Addison himself ap- 
pears to be somewhat exaggerated, in the light 
of our more accurate methods of blood study. The " anemiated 
eye " of Addison does not always mean anemia. In advanced 
cases the blood-picture may be characterized by marked hemo- 
globin and erythrocyte losses, by the presence of numerous 
poikilocytes and microcytes, and by small numbers of normo- 
blasts ; the hemoglobin readings in such instances range between 
20 and 40 per cent., and the erythrocyte counts between 2,000,- 
000 and 3,000,000 per cubic millimeter, or even less. Tschir- 
kofif 1 reports cases in which, notwithstanding the coexistence of a 
notable oligocythemia, the hemoglobin percentage remained 
normal or above normal, and this peculiar condition he referred 
to an increase in the amount of corpuscular reduced hemoglobin. 
This author also detected the presence of methemoglobin and 
melanin in the blood of patients suffering from Addison's disease. 
The polycythemia which is sometimes met with in this condition 
is doubtless to be attributed to such factors as vasomotor 
changes, and blood inspissation from emesis. Treatment with 
suprarenal extract tends to improve the anemia, but to what ex- 
tent and how permanently is undetermined. 

The number of leucocytes is usually normal, 
Leucocytes, or below normal, and extreme leucopenia has 
been repeatedly noted. Relative lymphocytosis 
and sometimes a moderate increase in the number of eosinophiles 
are the most familiar differential changes, together, in some in- 
stances, with the presence of a few myelocytes, and basophilic 
leucocytes. 

VI. ANTHRAX. 

In the light of our present knowledge nothing definite is known 
of the behavior of the hemoglobin and coi'pnscles in this infection. 
Only occasionally can the anthrax bacillus be isolated from the 
peripheral blood, since general invasion of the circulation by this 
organism is rare. Blumer and Young 2 succeeded in finding the 
organism in the blood of a single case of anthrax septicemia, both 
in ordinary cover-glass specimens, as well as by culturing. 

J Zeitschr. f. klin. Med., 1890, vol. xix., p. 87. 

2 Johns Hopkins Hosp. Bull., 1895, vol. vi., p. 127. 



3oo 



GENERAL HEMATOLOGY. 



VII. APPENDICITIS. 



Fully three-fourths of all cases of appendicitis, 
Hemoglobin whatever their character, show a loss of at least 
and 30 per cent, of hemoglobin, while in about one 
Erythrocytes, case in five the erythrocytes are diminished 1,000,- 
000 or more to the cubic millimeter. From an 
analysis of the cases tabulated below, it appears that the average 
hemoglobin loss amounts to about 25 per cent., and the average 
decrease in erythrocytes to about 1 5 per cent, of the normal 
standard. The anemia, which may usually be attributed to the 
effects of septicemia, is most frequent and most marked in long- 
standing cases of appendicular abscess, in which type of the dis- 
ease the hemoglobin may fall to between 30 and 40 per cent., 
and the corpuscles to between 2,000,000 and 3,000,000 per cubic 
millimeter. In such instances the risk, actual or reputed, of 
operating upon a patient having such a low percentage of hemo- 
globin must be recalled by the surgeon. Anemia, usually of a 
more moderate grade, is also frequently found in catarrhal cases, 
and in the individual instance it may reach as high a grade as in 
the purulent form of the disease. The blood impoverishment 
in such instances depends probably upon the debilitated state of 
the patient, apart from the appendix inflammation. 

The following table illustrates the range of the hemoglobin and 
erythrocytes, as shown by the initial examinations of 139 cases in 
Dr. J. B. Deaver's wards at the German Hospital : 



Number of Cases. 



Hemoglobin Percentage. 

Above 100 
From 90 to 100 

" 80 to 90 

" 70 to 80 

u 60 to 70 

" 50 to 60 

" 40 to 50 

" 30 to 40 

Highest : 
Lowest : 
Average : 

Erythrocytes per cb. mm. 

Above 5,000,000 

From 4,000,000 to 5,000,000 
" 3,000,000 to 4,000,000 
" 2,000,000 to 3,000,000 



Non-purulent. 

I 
I 

9 
13 
13 
6 
2 
o 

102 per cent. 

45 " 
69.5 « 

6 
27 
1 1 
1 



Purulent, Perforative, and 
Gangrenous. 

O 

4 
20 

3i 

2 3 
7 

6 

3 

too per cent. 
38 

72.5 " 



14 
60 
15 
5 



APPENDICITIS. 



30I 



Highest : 
Lowest : 
Average : 



5,660,000 per cb. mm. 5,710,000 per cb. mm. 
2,050,000 " " 2,100,000 " u 
4,295,955 " " 4,381,234 " 



Qualitative changes in the erythrocytes are neither common 
nor important, occurring only in cases with decided anemia, and 
consisting simply in deformities of shape and of size. Erythro- 
blasts apparently do not occur, although there is no reason why 
they should not, if the anemia happens to be of a type of sufficient 
severity to provoke marrow changes. 

In simple appendicular inflammation, uncompli- 
Leucocytes. cated by pus, gangrene, or peritonitis, there is as a 
rule little or no increase in the number of leuco- 
cytes, although in an exceptional case the leucocytosis is fairly 
well defined. Thus, of the 45 cases of this form of the disease, be- 
low referred to, less than 9 per cent, were accompanied by a count 
in excess of 1 5,000, the maximum estimate being 17,100, and the 
average, 8,987 per cubic millimeter. A relatively high count in 
this variety of appendicitis may usually be attributed to a limited 
periappendicular peritonitis. In some instances it is possible that 
the increase may be due to blood inspissation from vomiting and 
purging, or that it may simply represent a blood finding of the 
associated anemia. 

In cases with abscess, gangrene, or general peritonitis a well- 
marked leucocytosis is the general rule. Few cases of appen- 
dicular abscess fail to increase the leucocyte count to at least 
15,000 or 20,000 to the cubic millimeter, although it is to be 
remembered that should the purulent focus happen to be so 
effectually walled off that absorption of toxic material is prac- 
tically prevented, such a decided increase does not develop. A 
trivial increase, or, indeed, an absence of leucocytosis is also met 
with in an occasional grave case (such, for instance, as one com- 
plicated by a general purulent peritonitis), owing to the prostra- 
tion of the patient from the systemic poison of the infection. As 
shown below, the average count in purulent and gangrenous ap- 
pendicitis is higher than the maximum count in the catarrhal form 
of the affection. 

A high leucocytosis suggests either a localized abscess or a 
general peritonitis, for the differentiation of which other clinical 
data are absolutely essential. The belief is current that if a 
marked leucocytosis occurs early in the attack peritonitis is prob- 
able, and if it occurs after the first week a local accumulation of pus 
is suggested. While this is undoubtedly true in many instances, 
in many others the condition of the appendicular lesion may be 
wrongly interpreted, if too great reliance is placed on the behavior 
of the leucocytes in connection with the period of the attack. 



302 



GENERAL HEMATOLOGY. 



Increase in the purulent focus, and extension of peritonitis are 
betrayed by an increase in the leucocyte count, provided that the 
patient's powers of reaction are not too greatly crippled. In 
operative cases, thorough evacuation of the abscess is followed 
within a few days by a decline to normal in the number of leuco- 
cytes. Persistence of the leucocytosis after the third or fourth 
day following the operation may usually be attributed to undrained 
pus pockets or to a general peritonitis. 

In non-operative cases with abscess the leucocytosis, which 
becomes well-developed by the fourth or fifth day of the attack, 
persists but does not tend to increase if the lesion remains local- 
ized ; it gradually decreases as the pus collection disappears ; 
and it suddenly increases if the process extends. 

To sum up, absence of, or slight, leucocytosis suggests either (a) 
simple catarrhal appendicitis, (b) fulminant appendicitis, or (c) a lo- 
calized pus focus from which no absorption occurs. Well-marked 
leucocytosis indicates either (a) a local abscess from which ab- 
sorption of toxins occurs, (d) general peritonitis, or (c) gangrene. 

The following table shows the range of the leucocytes in the 
German Hospital cases to which reference has been made : 

Number of Cases. 



Leucocytes per cb. mm. 

Above 50,000 

From 40,000 to 50,000 
" 35,000 to 40,000 
" 30,000 to 35,000 
" 25,000 to 30,000 
" 20,000 to 25,000 
" 15,000 to 20,000 
" 10,000 to 15,000 

" 5,000 tO TO, OOO 

Below 5,000 

Highest : 
Lowest : 
Average : 



Non-purulent. 
O 

o 
o 
o 
o 
o 

4 
10 

25 
6 

1 7, 100 per cb. mm. 
1,600 " " " 
8,987 " " " 



Purulent, Perforative, and 
Gangrenous. 

I 

O 

2 

O 

6 
16 

38 
24 

7 
o 

58,500 per cb. mm. 
6,000 " " " 
17,955 " " " 



The qualitative changes found in high leucocyte counts are 
those typical of an ordinary polynuclear neutrophile leucocytosis 
— a large absolute and relative gain in polynuclear forms at the 
expense of the hyaline mononuclear cells. 

The conditions which may more or less closely 
Diagnosis, simulate an acute attack of appendicitis are nu- 
merous, and unfortunately it happens that just 
those lesions in which the resemblance is closest often produce 



APPENDICITIS. 



303 



blood changes identical with those of appendicitis. Thus, leuco- 
cytosis is the rule in pyosalpinx, ovarian abscess, ectopic pregnancy, 
pyoneplirosis, perinephritic abscess, hepatic abscess, empyema of the 
gall-bladder, and malignant disease of the cecum, all of which 
may be confused with an appendicular abscess. 

Such a large proportion of cases of hepatic and renal colic are 
accompanied with acute inflammatory complications, giving rise 
to leucocytosis, that these conditions cannot be differentiated 
with any degree of confidence from appendicitis, simply by an 
examination of the blood. The same is true of dysmenorrhea , 
in which inflammatory changes in the uterus may constitute the 
factor of a leucocyte increase. Acute gastritis is sometimes ac- 
companied by a well-marked leucocytosis, and sometimes by 
none at all, so that the blood count cannot be relied upon as a 
clue in distinguishing this disease from appendicitis. 

Simple ejiteralgia, and ovarian neuralgia may be ruled out, 
if a leucocyte increase is present, as also may be intestinal ob- 
struction, provided that the latter is not complicated by inflam- 
matory changes, by gangrene, or by malignant disease. In 
lead-colic there is often a pronounced leucocytosis, especially in 
patients with acutely toxic symptoms ; but granular basophilia of 
the erythrocytes can be detected even in the earliest stages of 
plumbism, while in appendicitis this change does not occur. 

The presence of a leucocytosis is sufficient to exclude a non- 
inflammatory ovarian cyst, and a movable kidney, and the same 
sign is of no little value in ruling out enteric fever, if no leuco- 
cyte-raising complications are apparent. 

The simple fact of the presence or absence of a leucocytosis is 
more often misleading than useful in the diagnosis of appendicitis, 
for this sign, to be of any real value, must invariably be corre- 
lated with other more definite clinical manifestations. Appendicitis 
should never be ruled out because leucocytosis is absent, nor 
should a moderate leucocyte count be considered an indication of 
the benignancy of the lesion. A count in excess of 20,000 may 
be relied upon as a certain sign of pus or its consequences, and 
is sufficient to warrant operative interference, if the symptoms 
point to the appendix as the seat of the trouble. Counts of less 
than 20,000 cannot be depended upon to reflect the character of 
the local lesion, since an increase to practically this figure may be 
found occasionally in mild catarrhal cases, as well as in those with 
purulent foci. In the writer's experience, the behavior of the 
leucocytes throws a much clearer light upon the progress of the 
disease, in both operative and non-operative cases, than it does 
upon the initial diagnosis, which should be determined chiefly by 
other clinical methods. 



304 



GENERAL HEMATOLOGY. 



VIII. ASIATIC CHOLERA. 

A number of investigators have drawn atten- 
General tion to the difficulty met with in many cases of 

Features, obtaining a sufficient quantity of blood for clin- 
ical examination, even from a deep puncture. 
This peculiarity, which has been attributed to excessive dryness 
of the tissues from drains upon the body fluids, is most pro- 
nounced in the algid stage of the disease. 

The great decrease in the alkalinity of the blood in Asiatic 
cholera, sometimes spoken of as an acid reaction, was first de- 
termined by C. A. Schmidt 1 by a series of elaborate analyses 
made in 1850, since which time similar findings have been noted 
by Cantani, 2 Straus, 3 and others. 

The specific gravity of the blood-mass is found to be increased, 
especially in those cases in which the blood is highly inspissated ; 
in such instances the specific gravity may rise to as high as 1073. 

The agglutination of cholera vibrios by the blood serum of 
cholera patients was first applied as a clinical test by Achard 
and Bensaude, 4 these investigators finding that the reaction may 
occur as early as the reputed first day of the illness, and as late 
as the fourth week after recovery. Clinically, the test may be 
made either with dried blood or with serum. 

The studies of Biernacki 5 and of Okladnych, 6 

Hemoglobin which together include the investigation of sixty- 
and two cases, furnish the most complete data con- 
Erythrocytes. cerning the changes affecting these elements. 

Both of these observers found a more or less 
marked polycythemia with a proportionate increase in the hemo- 
globin percentage, the erythrocyte count in many cases being 
between 6,500,000 and 7,500,000, and in one case reaching the 
remarkable maximum of 8,000,000. The increase may often be 
observed within a few hours after the onset of the infection. Con- 
centration of the blood is to be considered as the cause of these 
high counts, which are as a rule highest in cases characterized 
by pronounced emesis and purging. No constant relation between 
the degree of polycythemia and the gravity of the infection can 
be distinguished. 

1 " Charakteristik der epidemischen Cholera gegeniiber verwandlen Transsuda- 
tionsanomileen," Leipsig, 1850. 

2 Centralbl. f. die med. Wissenschaft. , 1894, vol. xxii., p. 785. 

3 Compt. rend. Soc. biol., Paris, 1883, vol. iv., p. 569. 

4 Presse med., 1896, vol. xvi., p. 504. 

5 Deut. med. Woch., 1895, vol. xxi., p. 795. 

6 Cited by Biernacki : loc. cit. 



ASTHMA AND EMPHYSEMA. 



305 



The above-quoted authors found high-grade 
Leucocytes, leucocytosis to be the almost invariable rule, 
the increase in leucocytes being not parallel 
with, but rather relatively greater than, the accompanying in- 
crease in erythrocytes. It occurs both in mild and in severe 
cases, as early as within twelve hours after the onset of the dis- 
ease, and as late as the third, fourth, or sixth day. It may be 
present both in the algid stage and in the stage of reaction, but is 
likely to be more decided in the former. The degree of leucocy- 
tosis may range from a minimum count of 14,000 to a maximum of 
60,000 cells per cubic millimeter, the case of average severity 
showing an increase to about 25,000 or 30,000. Pre-agonal 
leucocytosis may be pronounced, counts of 50,000 being not 
uncommon. Biernacki states that " all cases which in the algid 
stage show a leucocytosis of 40,000 to 60,000 soon prove fatal." 
On the contrary, an absence of leucocytosis cannot be regarded 
as a surety that the patient will recover. In a trivial infection 
distinct leucopenia has been observed, but this is rare. Concen- 
tration of the blood does not altogether account for the leucocy- 
tosis, for the influence of the specific infection as a factor is 
thought to be most active. 

The leucocytosis of Asiatic cholera is typically polynuclear, 
the increase affecting chiefly the polynuclear neutrophile cells, 
which may reach relative percentages of 90 or even 95, while 
the proportions of other forms are lower than normal. Sherring- 
ton 1 has found the mast cells notably increased in some instances. 

IX. ASTHMA AND EMPHYSEMA. 

In long-standing cases moderate secondary 
Hemoglobin anemia involving chiefly a hemoglobin loss may 
and be found, for in many instances the general de- 
Erythrocytes. bility of the patient or the presence of lesions of 
other organs is quite adequate to give rise to 
such a change. In cyanotic patients the anemia may be hidden 
by the polycythemia arising from circulatory disturbances, this 
deceptive blood concentration being most conspicuous during an 
asthmatic paroxysm. 

Little or no increase above the normal stand- 
Leucocytes. ard in the number of leucocytes is the usual con- 
dition, although these cells may show a consid- 
erable increase in cases associated with acute bronchitis, and also 

1 Proc. of the Roy. Soc, London, 1894, vol. lv., p. 189. 

20 



I 



306 GENERAL HEMATOLOGY. 

during an asthmatic attack. Gabritschewsky, 1 Fink, 2 von Noor- 
den, 3 Billings, 4 and others have called attention to the presence 
of an eosinophile increase in both asthma and emphysema. 
From 10 to 20 per cent, of this type of cells is not an unusual 
proportion, both in cases with and those without leucocytosis, 
while in one case Billings has reported three consecutive counts 
of 33.9, 38.2, and 53.6 per cent., respectively, with correspond- 
ing total leucocyte estimates of 7,600, 7,500, and 8,300 per cubic 
millimeter. In true bronchial asthma the eosinophile increase 
develops shortly before the paroxysm, and persists during and 
for a short time after it, disappearing in the interval between the 
seizures. This sign is regarded of value in differentiating true 
bronchial asthma from the dyspnea due to renal and cardiac le- 
sions, since in the latter the eosinophiles are never increased, and 
it is also considered of some clinical utility in heralding an 
impending asthmatic paroxysm, 

X. BRONCHITIS. 

j t With the exception of a slight oligochromemia, 

Hemoglobin , . , . f \, . *? fe ' 

which is frequently present in severe cases with 

high temperatures, the erythrocytes and their 
Erythrocytes. , fa , , t . ■ \ . J / n . . 

hemoglobin content remain practically normal in 

all forms of bronchial inflammation. 

Acute catarrhal bronchitis of the larger tubes 
Leucocytes, is ordinarily unattended by leucocytosis, but, un- 
fortunately for diagnostic purposes, an occasional 
case shows a marked increase. Thus, in four of Cabot's seventeen 
cases, 5 the counts were 17,600, 23,500, 26,000, and 41,000, re- 
spectively, while in eleven the leucocytes numbered more than 
10,000 per cubic millimeter. In chronic bronchitis leucocytosis 
rarely if ever occurs. The range of the leucocytes in capillary 
bronchitis and in croupous pneumonia may be identical. 

XL BUBONIC PLAGUE. 

Since 1 894, when Kitasato and Yersin, working 
Bacteriolog- independently,simultaneously discovered thebacil- 
ical Exam- lus pestis bubonic <z in the circulating blood of pa- 
ination. tients infected with plague, this organism has been 
repeatedly isolated from the blood by many dif- 
ferent observers. In a bacteriological study of twenty-seven cases 

1 Archiv. f. exp. Path. u. Pharm., 1890, vol. xxviii., p. 83. 

2 Inaug. Diss., Bonn, 1890. 

3 Zeitschr. f. klin. Med., 1892, vol. xx., p. 98. 

4 N. Y. Med. Journ., 1897, vol. lxv., p. 691. 

5 Loc. cit. 



BUBONIC PLAGUE. 



307 



Ogata 1 also frequently found in the blood, especially in severe in- 
fections, a micro-organism morphologically similar to Frankel's 
pneumococcus, the significance of this unidentified organism being 
undetermined. The same observer calls attention to the fact that 
blood from patients convalescent from nineteen to sixty -five days, 
although giving negative results by cultural methods, when in- 
jected into mice proves rapidly fatal to these animals, in whose 
tissues the plague bacillus may be recovered in pure culture. The 
relatively large number of positive results to be obtained from 
bacteriological blood examinations in this disease, especially in its 
septicemic form, attaches to the procedure no small diagnostic 
value. Cultural methods with blood drawn directly from a vein 
give, of course, the most favorable results, but the bacilli may be 
often detected in the stained cover-glass specimen of finger blood, 
in which they appear as short rods, tending to group together in 
chains or in pairs, exhibiting bipolar staining, and decolorizing by 
Gram's method. In view of the fact that the peripheral blood 
contains but small numbers of the bacilli, Rees 2 advises making 
large films on slides rather than cover-glass specimens, should 
direct examination of the stained film be attempted. 

The agglutination of the plague bacillus by the blood serum 
from plague subjects has been noted by a number of different 
investigators, but thus far no clinical application of the reaction 
has been made. The inconstancy with which the reaction occurs, 
for it may frequently be absent in both the mildest and the most 
severe cases, and the variable degrees of serum dilution neces- 
sary for its production appear to bar the acceptance of the test as 
a reliable diagnostic sign. 

According to Aoyoma's studies, 3 the hemo- 
Hemoglobin globin and the erythrocytes are both decidedly 
and increased above normal in the majority of cases. 

Erythrocytes. Of the six cases examined by this writer, five 
showed marked polycythemia, the highest count 
being 8, 190,000, and the average 6,976,666. Qualitative changes 
in the erythrocytes, it is to be presumed, do not occur, since no 
mention of such alterations is made. 

In two-thirds of the cases just quoted marked 

Leucocytes, increase in the number of leucocytes was found, 
the gain being greater than is ordinarily met with 
in any condition except leukemia ; the count exceeded 100,000 
in four instances, and averaged for the six 96,666. The increase 

1 Centralbl. f. Bakt. u. Parasit., 1897, vol. xxi.,p. 769. 

2 British Med. Journ., 1900, vol. ii., p. 1236. 

3 Mittheilungen aus d. Med. Fac. d. Kaiserlich-Japanischen Universitat, Tokio, 
1895, vol. iii., p. 115. 



308 general hematology. 

was due usually to a disproportionately large percentage of poly- 
nuclear neutrophiles, but in some cases " large and small mono- 
nuclear white cells " were observed. The identity of the latter — 
whether lymphocytes or myelocytes — must remain questionable, 
since all the differential counts were made with specimens stained 
with eosin and hematoxylin. The eosinophiles were, as a rule, 
conspicuous by their absence. 

The blood plaques were found to be notably increased in number. 

XII. CHOLELITHIASIS. 

In gall-stone complicated by phlegmonous 
General cholangitis or other purulent sequelae, hyperi- 
Features. nosis is observed, and coagulation is generally 
more rapid than normal, but in simple impacted 
calculi these changes are absent. The general effects upon the 
blood of bile, elsewhere noted, may also be detected when marked 
jaundice develops. ( See "■ Cholemia " and " Icterus.") 

Positive results from bacteriological examination of the blood 
have frequently been obtained in cholelithiasis, streptococci hav- 
ing been isolated by Netter, 1 staphylococci and colon bacilli by 
Sittmann, 2 streptococci and pneumococci by Canon, 3 and various 
bacteria of unknown identity by other investigators. 

Moderate oligochromemia is found in the 
Hemoglobin greater proportion of cases, but a decided loss 
and either of hemoglobin or of erythrocytes is com- 

Erythrocytes. paratively rare. In general terms, it may be 
conservatively stated that the hemoglobin loss 
on the average amounts to about 30 per cent, and that the cel- 
lular decrease approximates 15 per cent, of the normal standard. 
In occasional instances, notably those in which suppuration or 
sepsis coexists, the anemia is of a more intense grade, and may 
be associated with various changes indicative of cellular degen- 
eration. In 28 cases of cholelithiasis at the German Hospital the 
following estimates of the hemoglobin and erythrocytes were 
obtained at the initial examinations : 



Hemoglobin 


Number 


OF 




Erythrocytes 




Number of 


Percentage. 


Cases. 






per cb. mm 




Cases 


From 80 to 90 


5 


Above 


5 


000,000 




3 


" 70 to 80 


10 


From 


4 


000,000 to 5,000 


OOO 


13 


" 60 to 70 


8 


( i 


3 


000,000 to 4,000 


OOO 


10 


" 50 to 60 


4 


( ( 


2 j 


000,000 to 3,000 


OOO 


2 


'■' 40 to 50 


0 












" 30 to 40 


0 












" 20 to 30 


1 













1 Progres med., 1886, vol. xiv., p. 992. 

2 Deut. Archiv. f. klin. Med., 1894, vol. liii., p. 323. 

3 Deut. med. Woch., 1893, vol. xix., p. 1038. 



DIABETES MELL1TUS. 



309 



Average: 70.6 per cent. Average: 4,131,785 per cb. mm. 

Maximum: 85.0 £< Maximum: 5,390,000 " " 

Minimum: 28.0 " Minimum: 2,510,000 " " 

Simple gall-stone does not of itself excite the 
Leucocytes, slightest increase in the number of leucocytes, 
but nevertheless leucocytosis, typically polynu- 
clear in type, is a rather common feature of the blood-picture in 
this disease, owing to the fact that such a large percentage of 
cases is complicated by acute inflammatory changes. Ten of 
the 28 cases just mentioned had a count of more than 10,000 
cells to the cubic millimeter. The following resume of the ex- 
aminations illustrates the range of leucocytes in the series : 

Leucocytes per cb. mm. 

From 15,000 to 20,000 in 7 cases. 

" 10,000 to 15,000 " 3 " 

" 5,000 to 10,000 " 16 " 
Below 5,000 " 2 " 

Average : 10,164 per cb. mm. 
Maximum: 18,800 " " " 
Minimum: 4,600 " " " 

The presence of a leucocytosis excludes simple 
Diagnosis. biliary colic, and indicates as the cause of the in- 
crease some other lesion, such, for example, as 
phlegmonous cholangitis or cholecystitis, hepatic abscess, peritonitis, 
or malignant disease. Hepatic and renal colics cannot be differ- 
entiated by the blood count. 

XIII. DIABETES MELLITUS. 

The alkalinity of the blood, according to the 
General general consensus of opinion, is appreciably 
Features. diminished, especially in cases in which coma 
either impends or exists. Lipemia is not uncom- 
mon, the amount of fat in some instances being so large as to pro- 
duce a milky appearance of the blood drop, evident to the naked 
eye, although in most instances the condition is recognizable only 
by the detection of fat-globules under the microscope. Lipaci- 
demia may be detected in diabetic coma. Glycemia is present, and 
can be demonstrated by the detection of grape-sugar in relatively 
large amounts, even as great as 5.7 parts per thousand, according 
to Grawitz, 1 or 9 parts per thousand, according to Hoppe-Seyler. 2 
Williamson 's Test. This reaction, devised by Williamson 3 in 
1 Loc. cit. 

2 Virchow's Archiv., 1858, vol. xiii., p. 104. 

3 British Med. Journ., 1896, vol. ii., p. 730. Also, Lancet, 1900, vol. ii., p. 320. 



GENERAL HEMATOLOGY. 



1896, depends upon the fact that a warm alkaline solution of 
methylene-blue is decolorized when mixed with a minute quantity 
of glucose. Twenty cubic millimeters of the suspected blood, 
obtained by puncturing the finger, are measured by means of 
Gower's hemocytometer pipette, and blown out into 40 cubic 
millimeters of distilled water contained in a small test-tube. To 
this mixture are then added, in the order given, 1 cubic centi- 
meter of a 1 : 6,000 aqueous solution of methylene-blue, and 40 
cubic millimeters of a six-per-cent. aqueous solution of potassium 
hydrate. In a second test-tube the same proportions of normal 
blood and reagents are mixed, to be used as a control. The 
color of both mixtures is precisely the same — moderately deep 
bluish-green. Both tubes are placed in a beaker filled with boil- 
ing water, in which they are allowed to remain for four minutes, 
at the end of which time the test-fluid containing the diabetic 
blood will have turned a dingy yellow color, while the color of 
the control mixture remains unchanged. Care must be taken to 
use not more than 20 cubic millimeters of blood, since a positive 
reaction may be more or less closely counterfeited with non-dia- 
betic blood, should three or four times this quantity be employed. 
It is essential, therefore, to measure the 'blood accurately, and 
not to trust to the approximate method used by some, of simply 
taking two drops of blood as the equivalent of the required 20 
cubic millimeters. 

Williamson's reaction is presumably due solely to the action of 
the grape-sugar contained in diabetic blood, and if this proves 
true, it is not unreasonable to predict that the principle of the test 
may be elaborated into a method for estimating the percentage 
of sugar in the blood. Positive reactions occur constantly in 
diabetes, sometimes even after the disappearance of every trace 
of sugar from the urine, and, so far as investigations up to the 
present time have shown, negative results are invariably met with 
in other diseases. 

Bremer's Test. Bremer, 1 having noticed in diabetes mellitus 
peculiar affinities of the erythrocytes for various aniline dyes, has 
devised upon this basis an ingenious test for the recognition of 
diabetic blood. Several thick films from a suspected case, con- 
trolled by the same number of preparations made from normal 
blood, are prepared, preferably on slides, and heated in an oven 
to a temperature of 13 5 0 C, after which they are set aside to 
cool. Both sets of films are then stained for about two minutes 
with a one-per-cent. aqueous solution of Congo-red (mixed freshly 

J N. Y. Med. Journ., 1896, vol. lxiii., p. 301. {Lit.) Also N. Y. Med. Record, 

1897, vol. xii., p. 495. 



DIABETES MELLITUS. 



311 



just before using), thoroughly washed in running water, and 
dried between bits of filter-paper. Thus treated, diabetic blood 
is either colored pale greenish-yellow or is entirely unstained, 
while normal blood stains typically the red color of the dye. 
Using the same method of heat fixation, other aniline dyes may 
be employed to demonstrate this peculiar behavior of diabetic 
blood. For example, with a one-per-cent. aqueous solution of 
methylene-blue the diabetic specimen stains yellowish-green, and 
the normal film blue. Diabetic blood, on the contrary, treated 
with a one-per-cent. aqueous solution of biebrich-scarlet, takes 
the color of the dye in a typical manner, while normal blood re- 
mains practically uncolored. Ehrlich's triacid stain, as well as 
mixtures of methylene-blue and eosin, and methyl-green and 
eosin, have also been used to demonstrate the reaction. The 
cause of Bremer's reaction is unknown, but apparently it is not 
due to the effect of glucose ; many authors are inclined to attrib- 
ute it to excessive acidity of the blood. Positive results with 
this test can not be regarded as pathognomonic of diabetes mel- 
litus, since they have been reported with the blood of persons suf- 
fering from exophthalmic goitre, multiple neuritis, leukemia, and 
Hodgkin's disease. 

There are no constant changes to be found in 
Hemoglobin these elements. Normal hemoglobin percent- 
and ages and erythrocyte counts are observed in 
Erythrocytes, most cases, while in others in which the cachexia 
is pronounced, a well-marked secondary anemia 
may exist. James, 1 in a study of 13 cases, found the number 
of erythrocytes over 6,000,000 in 5 ; 5,000,000 plus in 5 ; 4,000,- 
000 plus in 2 ; and 3,000,000 plus in 1. The hemoglobin per- 
centage was over 100 in 3 cases ; 60-70 in 8 ; and 50-60 in 2. 
The alterations in the hemoglobin and erythrocytes in diabetes 
have been attributed by the older writers 2 chiefly to the effects of 
blood concentration and dilution. Thus, it was believed that in 
cases with excessive polyuria the blood became inspissated and 
the count thus increased, while in cases with pronounced gly- 
cemia the blood became diluted and the count lowered, as a con- 
sequence of the fluid transfer from the tissues into the capillaries 
provoked by the presence in the blood of a large percentage of 
sugar. It is obvious that these influences, if active, are sufficient 
to render the blood count in diabetes of little or no practical 
value, since on the one hand, perfectly normal blood, if diluted, 

1 Edinburgh Med. Journ., 1896, vol. xlii., p. 193. 

2 Lit. cited by Leichtenstern : " Unters. iiber d. Hg-Gehalt d. Blutes," Leipzig, 
1878. 



312 



GENERAL HEMATOLOGY. 



may appear anemic, while on the other hand, anemic blood, if 
concentrated, may seem normal. James 1 contends, however, 
that the polycythemia is real, and is not dependent upon inspis- 
sation, for were the increase merely relative it would naturally be 
accompanied by an increase in the density of the blood, and this 
in his experience never occurred, the specific gravity figure for 
his series ranging between 1054 and 1060. 

High digestion leucocytosis is the most con- 
Leucocytes. stant change affecting these cells, but this is not 
found in every case. Isolated examples of leu- 
cocytosis, apparently independent of this influence, have been re- 
ported, but in the great majority of diabetics the leucocyte count 
is normal. The presence of small numbers of myelocytes in 
cachectic patients is the only qualitative change to which atten- 
tion has been directed. Mahogany-colored granules, either within 
the leucocytes or extracellular, may usually be demonstrated by 
the iodine method. The prevalent view that this reaction is due 
to the presence of glycogen has been disputed by some (see page 
175)- 

No numerical change in the blood plaques has been reported. 

Williamson's reaction is of real value, especially 
Diagnosis, in the recognition of cases with temporary disap- 
pearance of sugar from the urine and in dia- 
betic coma. Bremer's test and the iodine reaction are to be 
regarded as symptomatic, not necessarily of diabetes. The 
other blood findings are without diagnostic value. 

XIV. DIPHTHERIA. 
Usually the changes in the hemoglobin and 
Hemoglobin erythrocytes are, at the most, trifling, for in 
and about two-thirds of all cases these elements are 
Erythrocytes, practically normal, while in the other one-third 
moderate anemia, more marked in severe than 
in mild cases, is found. The anemia does not develop until 
about the middle of the first week of the disease, and is as a 
rule characterized by a diminution of hemoglobin roughly pro- 
portionate to the corpuscular loss. Degenerative changes are rare, 
consisting usually of nothing more than occasional polychromato- 
philia ; nucleation and deformities of size and of shape are absent. 
Regeneration of the blood takes place slowly, and, as the loss of 
hemoglobin is made up less rapidly than that of the corpuscles, 
the color index, which is approximately normal early in the dis- 
ease, later falls considerably. 

1 Loc. cit. 



DIPHTHERIA. 



313 



The loss of hemoglobin does not often exceed 15 per cent., 
nor is the decrease of erythrocytes usually greater than from 
500,000 to 750,000 cells to the cubic millimeter. Concentration 
of the blood, which frequently occurs during the febrile period, 
may cause striking temporary polycythemia. 

Morse 1 in single examinations of 30 cases, treated without 
antitoxin, found the count of erythrocytes above 5,000,000 in 
21, and below 4,000,000 in but a single instance, a woman with 
chronic anemia ; several of his counts were in the neighborhood 
of 6,000,000. From this author's recent monograph 2 the fol- 
lowing counts reported by other investigators are taken : Bouchut 
and Dubroisay, 3 4,305,000 as the mean average of 93 counts in 
84 cases ; Gilbert, 4 an average of 4,500,000 in 58 counts in 22 
cases; Carter, 5 an average of 4,253,000 in 13 cases; and File, 6 an 
average of 4,588,000 in 18 counts in 10 cases, some of which had 
received antitoxin. Billings 7 in a painstaking study of 7 cases, 
untreated with antitoxin, in which 36 counts were made, found a 
moderate but distinct decrease in hemoglobin and erythrocytes 
in 5 cases, the loss first becoming apparent by the third or 
fourth day, and being proportionate to the severity of the infec- 
tion. This author's first counts, all made during the first week 
of the disease, ranged from 5,200,000 to 6,122,000, the average 
being 5,611,285, the hemoglobin for the same period ranging 
from 70 to 98 per cent, and averaging 90 per cent. Subsequent 
counts in this series showed that the greatest loss of hemoglobin 
averaged 12 per cent., ranging from 1 to 30 per cent., and that 
the maximum corpuscular loss averaged 878,500, varying from 
227,000 to 2,040,000. 

It is generally observed that in cases treated with antitoxin 
the anemia is decidedly less than in those treated by other 
methods, and in fact a majority of cases thus treated suffer no 
decrease at all. 

Well-marked leucocytosis, beginning probably 
Leucocytes, within a few hours after the infection first occurs, 
characterizes the average case of diphtheria of 
moderate severity. An analysis of the statistics derived from 276 
counts made by reliable investigators 8 shows that over 90 per 

1 Boston Med. and Surg. Journ., 1895, vol. cxxxii., pp. 228 and 252. 

2 Med. and Surg. Reports of the Boston City Hospital, 1899, loth series, p. 138. 

3 Compt. rend. Soc. biol., Paris, 1877, vol. lxxxv. , p. 158. 

4 Traite de Med. Charcot- Bouchard, vol. ii., p. 485. 

5 Univ. Med. Mag., 1894-95, vol. vii., pp. 17, 81, and 158. 

6 Lo Sperimentale, 1896, vol. 1., p. 284. 

7 N. Y. Med. Record, 1896, vol. xlix., p. 577. 

8 Ewing, Morse, Billings, Carter, Schlesinger, File, Gabritschewsky, Bouchut and 
Dubroisay, Rieder, Felsenthal, and Gilbert. 



3H 



GENERAL HEMATOLOGY. 



cent, of all cases are accompanied by a more or less marked 
increase in the number of leucocytes. 

In the majority of cases the number of leucocytes is not in- 
creased above 30,000 per cubic millimeter, but a much greater 
leucocytosis is sometimes encountered. Thus, the maximum 
counts of several authors are as follows : Felsenthal, 148,229 ; l 
Ewing, 72,000 f Gabritschewsky, 5 1,000 ; 3 Morse, 48,000 ; 4 
Carter, 48,280 ; 4 Billings, 38,600;* and Gilbert, 31, 000. 4 

This increase is to be regarded as a rough gauge of the reac- 
tion of the individual against the effects of the toxic products of 
the disease ; it is, therefore, absent in very mild cases, where little 
or no reaction is excited, and in very severe cases in which the 
patient's resisting powers are overwhelmed by the intoxication. 

In favorable cases the maximum leucocytosis is reached coin- 
cidentally with the height of the disease, and the increase gradually 
fades away during convalescence, having in most cases entirely 
ceased by the time the membrane has disappeared, but occa- 
sionally persisting after the subsidence of all local and systemic 
manifestations of the illness. In unfavorable cases high leucocyte 
counts persist until death, or " in somewhat prolonged cases, 
with much septic absorption, there may be an uninterrupted 
decrease of leucocytes continuing up to the fatal termination." 
(Ewing.) No constant relation has been determined between the 
leucocytosis and the extent of the local lesion, the degree of 
tonsillar and glandular swellings, or the height of the fever, 
although in individual cases some authors have suggested that 
such relationship may be distinguished. 

The effects of antitoxin upon the leucocytes are well illustrated 
by the conclusions of Ewing, 4 based upon 228 counts made in 53 
cases, before and after the injection of the serum. As the result 
of these investigations this author concludes that antitoxin, within 
thirty minutes after its injection, causes a hypoleucocytosis. In 
favorable cases, after the injection, the original height of the 
leucocytosis is not again attained, but in severe and less favor- 
able cases, the dose of antitoxin is followed in a few hours by 
a hyperleucocytosis exceeding that found in the primary count. 
In malignant cases the administration of antitoxin may be fol- 
lowed immediately either by rapid hyperleucocytosis or by ex- 
treme hypoleucocytosis and death. Bize 5 finds that in some 
cases the initial serum injection may not affect the leucocytes be- 

iArchiv. f. Kinderheilk., 1893, vol. xv. , p. 78. 
2 N. Y. Med. Journ., 1893, vol. lviii., p. 713. 
3 Annal. de l'lnstitut Pasteur, 1 894, vol. viii., p. 673. 
4 Loc. cit. 

5 Archiv. de med. des enf., 1901, vol. iv., p. 102. 



DIPHTHERIA. 



315 



cause of the insufficiency of the dose, and that repeated injections 
are sometimes required to modify the count. This investigator 
has also called attention to the pronounced leucocytoses which 
accompany eruptions due to antitoxin. 

The leucocytosis of diphtheria as a rule involves the polynu- 
clear neutrophile cells, most cases showing about 80 per cent, 
of this variety, but in an occasional instance there may be a 
well-marked increase in the mononuclear forms, considerably in 
excess of the percentage found in health. Relative lymphocy- 
tosis has been observed both during convalescence and in fatal 
cases with leucopenia, and absolute lymphocytosis may occur at 
the height of the disease in cases with high total leucocyte counts. 

Besredka 1 believes that marked polynuclear leucocytosis is a 
good prognostic sign, especially if this form of cells shows a 
strong tendency to increase after injection of antitoxin. On the 
contrary, cases which fail to show such a change he regards as 
grave, usually as fatal. This characteristic of high percentages 
of polynuclear neutrophiles is also regarded by many other 
authors as a favorable clinical sign, and a low percentage un- 
favorable. 

Ewing, 2 by staining the leucocytes with gentian-violet (50 cc. 
of normal salt solution to which 1 drop of a saturated alcoholic 
solution of gentian-violet is added), has deduced certain conclu- 
sions from the reaction of the leucocytes to this dye, to which he 
is inclined to attribute great prognostic value. He believes that 
the numbers and percentages of poorly stained leucocytes, and 
usually of ameboid figures, invariably increase in unfavorable 
cases, without relation to the total number of cells found in the 
blood. In his experience any considerable increase of poorly 
stained leucocytes, especially if associated with a decrease of the 
well-stained cells, was invariably the forerunner of a grave or 
fatal change in the patient's condition. In favorable cases, after 
treatment with antitoxin, he noted that the polymorphous forms 
show a decidedly increased affinity for gentian-violet, this char- 
acteristic often being observed within twelve hours after the in- 
jection of the serum. Failure of this peculiarity to develop he 
regards as a very unfavorable prognostic sign. Up to the present 
time these observations have not been verified by other investi- 
gators. 

The proportion of eosinophiles is exceedingly variable, these 
cells sometimes being absent, and at other times found in large 
numbers — 4 or 5 per cent. 

1 Annal. de l'lnstitut Pasteur, 1898, vol. xii., p. 305. 
2 Loc. cit. 



3i6 



GENERAL HEMATOLOGY. 



Engel 1 found variable percentages of myelocytes in both favor- 
able and unfavorable cases, especially in the latter, and he con- 
siders the presence of these cells in relatively high percentages 
(2 per cent, or higher) as an unfavorable prognostic indication. 
In 7 of Engel's fatal cases the percentage of myelocytes ranged 
from 3.6 to 14.6, but these cells never exceeded 1.5 per cent, in 
patients who recovered. An absence of myelemia, however, is 
no guarantee of recovery, for this sign is absent in about one out 
of every four fatal cases. 

Examination of the blood in diphtheria gives 

Diagnosis, no information which is not more clearly shown 
by other clinical signs, and it must be regarded 
as of no value as an aid to diagnosis. The leucocytosis in this 
disease, if the very benign and the very severe cases are excluded, 
is, as a rule, proportionate to the intensity of the infection. 

From a prognostic point of view, it appears that, as in pneu- 
monia, an absence of leucocytosis occurring in obviously severe 
infections is an unfavorable indication. The presence of a large 
percentage of myelocytes has a similar meaning. Pronounced 
lymphocytosis is also regarded as an unfavorable prognostic 
sign. 

XV. ENTERITIS. 

In acute catarrhal enteritis the same changes occur that are 
found in acute gastritis, namely, little or no alteration in the 
hemoglobin and erythrocytes, and an inconstant, moderate leuco- 
cytosis. Profuse watery dejecta lead, of course, to more or less 
blood concentration, by depletion of the body fluids, and hence 
polycythemia may be a transient sign. In chronic enteritis and 
gastro-e?iteritis, the interference with the patient's nutrition plus a 
drain upon the albuminoids may in course of time give rise to a 
decided anemia. Leucocytosis is not a characteristic of such 
cases. In dysentery and in ulcerative and phlegmonous enteritis, 
acute forms of secondary anemia are frequently met with, espe- 
cially in patients who pass much blood by the bowel. 

The effects upon the blood of saline purges were first deter- 
mined by Brouardel, 2 and later studied by Grawitz 3 and by Hay/ 
The investigations of these authors have shown that the adminis- 
tration of a purgative dose of Epsom or Glauber salt is followed 
within about thirty minutes by an appreciable increase in the 
number of erythrocytes, and that within an hour the count of 

1 Deut. med. Woch., 1897, vol. xxiii., pp. 118 and 137. 
2 Union med., 1897, vol. xxii., p. 405. 

3 Loc. cit. 

4 Journ. of Anat. and Physiol., 1882, vol. xvi., p. 430. 



ENTERIC FEVER. 



317 



these cells is fully 1,500,000 more than before the purge was 
given ; three hours after this maximum is reached the count is 
again normal. When a certain degree of concentration is ob- 
tained by this means, continued administration of the salt pro- 
duces neither additional concentration nor further purgation. 
Common table salt is also a most energetic factor of blood den- 
sity, even more so than either Epsom or Glauber salts. Purga- 
tive doses of jalap, croton oil, and other drugs of this class are 
also followed by more or less polycythemia. 

XVI. ENTERIC FEVER. 

Invasion of the blood by the bacillus typhosus 
Bacteriology, is of such relatively uncommon occurrence that 
bacteriological examinations in enteric fever, for 
diagnostic purposes, are of slight practical value. From an 
analysis of 210 cases examined by reliable investigators, using 
approved technique, the specific organism of the disease was ob- 
tained by culture in but 78 instances — an average of 37 per cent, 
of positive results in all cases. These figures, however, should be 
applied only to the average, and not to the individual case, for 
many competent workers have obtained lower averages, or have 
been uniformly unsuccessful in attempting to isolate the bacillus 
from the blood, while others have reported much higher per- 
centages of successful results. 

Kiihnau 1 made cultures in 41 cases, of which number positive 
results were obtained in 1 1 . James and Tuttle 2 carefully examined 
39 cases, and succeeded in obtaining the organism in 3. Wiit- 
schour, 3 in his examinations of 3 5 cases, found the bacillus in 
only a single instance. Of 16 cases examined by Castellani, 4 
blood cultures were positive in 4 ; of the patients giving positive 
findings, 3 died. Opposed to the foregoing results are the unusu- 
ally high percentages of positive findings reported by Cole, 5 who 
used from 8 to 10 cubic centimeters of blood, aspirated from a 
vein of the arm. This investigator obtained growths of the bacil- 
lus in 1 1 of the 1 5 cases examined, positive results being found 
as early as the sixth day of the disease, in both mild and severe 
cases. Schottmuller 6 also reports an unusually high proportion 
of successful findings, this investigator having isolated the typhoid 
bacillus in 40 out of 50 cases whose blood he examined. Thie- 

1 Zeitschr. f. Hyg. u. Infectionskr., 1897, vol. xxv., p. 492. 

2 Med. and Surg. Reports of the Presbyterian Hosp., N. Y., 1898, vol. iii., p. 46. 

3 Rev. Centralbl. f. Bakteriol. u. Parasit., 1890, vol. xiv., p. 279. 
4 Centralbl. f. Allg. Path. u. pathol. Anat., 1900, vol. xi., p. 456. 
5 Johns Hopkins Hosp. Bull., 1901, vol. xii., p. 203. 

6 Deut. rued. Woch., I900, vol. xxvi., p. 511. 



3 x8 



GENERAL HEMATOLOGY. 



mich 1 studied 7 cases, with positive results in 4 — in a single in- 
stance from venous blood, and in 3 from the rose-spots. Stern 2 
investigated 6 cases, obtaining growths in 3, the bacillus being 
isolated from the rose-spots in one, and from the blood in the 
other 2. Gwyn 3 has recently reported a case with typical clinical 
manifestations of enteric fever, in which he obtained cultures, 
made from the blood at the height of the disease, of a bacillus 
having cultural properties almost identical with the para-colon 
bacillus of Widal. In the late stages of the disease pyogenic 
bacteria have been found in the blood. 

Examination of the Rose-spots. Formerly the cultivation of 
typhoid bacilli from the rose-spots was attended by indiffer- 
ent success, but the favorable results with this procedure recently 
announced by a number of authors must stamp it as a distinct aid 
to the diagnosis of typhoid. Neufeld, 4 basing his experiments 
upon the belief that the bacteria lodge and multiply in the spots 
protected from the bactericidal action of the blood, examined 
these lesions in 14 cases and obtained positive results in 13. His 
findings were soon corroborated by the work of Curschmann, 5 
who found the bacilli in 14 out of 20 cases ; of Richardson, 6 whose 
results were positive in 5 out of 6 cases ; and of Scholz and 
Krause, 7 who found bacilli in the spots in 14 out of 16 cases ex- 
amined. The latter investigators emphasize the statement that 
the bacilli are prone to disappear from the spots after from three 
to five days, and that, to ensure the best results, the exami- 
nations must be made as soon as possible after the appearance of 
the roseola. All investigators agree that, in the great majority of 
instances, spot cultures give positive results several days before 
the appearance of the serum test. The chief disadvantages to 
this method of diagnosis appear to be the absence of the roseola 
in some cases, its late development in others, and the possibility 
of not always being able to distinguish typhoid spots from other 
eruptions. 

The technique used by Richardson 8 is simple, and judging 
from his results, trustworthy. After having washed the skin of 
the part with alcohol and ether, the spot is frozen with an ethyl- 
chloride spray, after which it is crucially incised. Its substance 

1 Deut. med. Woch., 1895, vo ^ xx i-> P- 55°- 
2 Centralbl. f. inn. Med., 1896, vol. xvii., p. 1 249. 

3 John Hopkins Hosp. Bull., 1898, vol. ix., p. 54. 

4 Zeitschr. f. Hyg., 1899, vol. xxx., p. 498. 

5 Munch, med. Woch., 1899, vol. xlvi., p. 1597. 
6 Phila. Med. Journ., 1900, vol. v., p. 514. 

7 Zeitschr. f. klin. Med., 1900, vol. xli., p. 405. 

8 Loc. cit. 



ENTERIC FEVER. 



319 



is then removed by scraping with a small skin-curette, and trans- 
ferred to a tube of nutrient bouillon. A second tube is inoculated 
with the blood which collects as soon as the effects of freezing 
have worn off, both cultures being then incubated and examined 
in the usual manner. At least five or six spots should be thus 
treated in each case, and two tubes, one for the scrapings, the 
other for the blood inoculation, used for each spot. 

If blood-serum from a case of enteric fever is 
Serum Test, mixed with a broth culture of the bacillus typho- 
sus, and a small drop of this mixture placed 
upon a slide and examined under the microscope, it will be ob- 
served that the bacilli, instead of continuing to dart actively to and 
fro across the field, as they do in the pure culture, are attracted 
to each other, lose their power of propulsion, and become grouped 



Fig. 42. 




A POSITIVE REACTION. 

Large clumps of motionless bacilli separated by open spaces. The few bacteria outside the clumps 
are devoid of motility. 

together in large agglutinated clumps of irregular outline, which, 
after the lapse of a variable length of time, become more and 
more compact and homogeneous. In the typical positive reac- 
tion the field of the microscope shows islands of clumped bacilli, 
separated from each other by large open spaces, containing per- 
haps a few isolated organisms the motility of which is decidedly 
inhibited at first, and finally entirely lost. If the clumps are of 
very large size, they produce a peculiar grayish mottling of the 
specimen visible to the naked eye, a point to which attention 
was first directed by Greene. 1 In a small proportion of cases 



*N. Y. Med. Record, 1896, vol. 1., pp. 697 and 805. 



3 20 



GENERAL HEMATOLOGY. 



the clumps appear to undergo a granular change, and then be- 
come entirely destroyed ; in some instances they remain un- 
altered for several days ; and in still others they may break up 
after a few hours, the field then becoming refilled with isolated, 
actively motile bacteria. 

Fig. 43. 




A PSEUDO-REACTION. 

A few small clumps of bacilli having impaired motility. Persistent motility of the bacteria in other 

parts of the field. 

In a certain percentage of instances the agglutinated, motion- 
less masses of bacilli may be observed as soon as the specimen is 
brought into focus, so that the reaction may be said to have 
taken place immediately. In other instances some little time 
elapses before the character of the test can be determined, and in 
such reactions the formation of the clumps, from their inception 
out of two or three bacteria, to their completion, when they con- 
sist of several hundred organisms tightly glued together into a 
densely crowded mass, may be studied most advantageously. In 
these slower reactions, while early clumping may progress to 
some extent, many isolated bacteria are seen the motility of 
which persists for a variable period, gradually growing less and 
less, until finally, with more or less crippled powers of propulsion, 
the organisms are attracted to the clump centers with which they 
are ultimately incorporated, either becoming adherent at first ap- 
proach, or, as is usually the case with the more active bacilli, 
circling around the edges of the clump for some little time before 
becoming attached to it. Still other reactions are characterized 
by an almost immediate cessation of motility, followed by tardy 
agglutination, and usually by the formation of clumps of smaller 
size than those noted in a prompt and immediate reaction. 



ENTERIC FEVER. 



321 



If the reaction is negative, the motility of the bacilli persists 
and the formation of clumps is not observed, regardless of the 
time during which the specimen is watched. Not unless aggluti- 
nation is marked and entire loss of motility occurs may a reaction 
be considered positive ; and pseudo-reactions resulting in the for- 



mation of small masses of more or less motile organisms, together 
with persistent motility of many unclumped bacteria in other 
parts of the field, cannot be regarded as typical in any sense. 
Clumping of small numbers of bacteria sometimes occurs in the 
pure culture during its growth, and this source of error must be 
eliminated by habitually examining the culture before each test 
or series of tests. 

Technique. In order to exclude all sources of error, such as 
may arise from the clumping of the typhoid bacillus by non- 
typhoid serum, provided that the latter is sufficiently concentrated 
and is allowed enough time to exert its agglutinative powers, the 
reaction can be considered of diagnostic value only under the 
following two conditions : first, that the blood to be tested must 
always be diluted with at least ten volumes of the culture ; and, 
second, that loss of motility and clump formation must occur 
within an arbitrary time limit of thirty minutes. Under these 
conditions it has been shown that agglutination of the typhoid 
bacillus is produced only by the blood from a patient who is or 
who has been infected with enteric fever. In some cases of ty- 
phoid the reaction occurs in much higher dilutions, frequently 
with dilutions of 1:50, or 1:100, or even higher. Some habitually 



Fig. 44. 




Bacillus typhi abdominalis. 



The bacilli are actively motile throughout the field. 



21 



322 



GENERAL HEMATOLOGY. 



work with higher dilutions than 1:10, but they extend the time 
limit of the reaction proportionately to the degree of the dilution 
used. 

Cultures from twelve to twenty-four hours old, grown in 
neutral peptone-bouillon from a stock agar-agar culture, are best 
adapted for the test. It is advisable to keep all the cultures at 
room temperature, and to transplant the stock agar growths not 
oftener than once a month, since cultures " forced" by incuba- 
tion and by frequent transplanting may give rise to false reactions 
with non-typhoid blood. The cultures should, of course, be ab- 
solutely uncontaminated, and must respond typically to the 
recognized tests for their identification. 

The test may be conducted either microscopically, by the dried 
blood method, or by the use of fluid blood, or fluid serum ; or 
macroscopically, the method preferred by Widal. 1 

The dried blood method, perfected and popularized by Wyatt 
Johnston, 2 is to be chosen whenever it is necessary to send the 
blood sample any distance for examination, and where the ex- 
aminer finds it inconvenient to carry with him to the patient's 
bedside the test-tubes required for the methods next to be de- 
scribed. Johnston's method is especially adapted for use by 
Health Boards, by which bodies it is now extensively employed 
in nearly all the large cities in this country. 

The technique of collecting the blood specimens is exceedingly 
simple. After having punctured the finger or ear in the usual 
manner, several separate drops of blood are collected upon the 
surface of some non-absorbent material, preferably glass, then 
dried, placed in an envelope or other protective covering, and 
tested at the examiner's convenience. Glass slides, or slips of 
non-absorbent Bristol board or paper are most commonly used 
for collecting the blood samples, and specimens thus obtained 
may be kept for several months without aseptic precautions, and 
still retain their agglutinative powers. 

If the specimen has been collected on glass, one of the crusts 
is moistened with a drop of sterile water and worked up into a 
thin paste with a platinum loop, after which complete solution 
and proper dilution of the blood is effected by adding nine drops 
of typhoid bouillon and mixing thoroughly. If the sample has 
been dried on a paper or cardboard surface, the blood crust may 
be cut out with a pair of scissors, and placed to soak, face down- 
ward, in a watch-glass containing ten drops of the culture. 

From one of these mixtures of blood and typhoid culture a 

1 Bull. med. , 1896, vol. x., pp. 618 and 766. 
2 N. Y. Med. Journ., 1896, vol. lxiv., p. 573. 



ENTERIC FEVER. 



323 



minute portion is transferred to the center of a clean cover-glass, 
which is at once inverted over a " concave slide," sealed with 
cedar-oil, and examined as a hanging-drop with a one-eighth- 
inch dry objective, using dim illumination. A plain glass slip is 
used by many workers, instead of a "hollow-slide," but either 
will prove satisfactory. 

If the fluid blood method is used, the dilution is made at the 
patient's bedside, by adding one drop of the whole blood, as it 
flows from the puncture, to ten drops of typhoid bouillon, con- 
tained in a small test-tube. The mouth of the tube is then closed 
by a cotton plug, and its contents thoroughly mixed by vigorous 
shaking. At the time of the test, which must not be delayed 
more than a few hours after the dilution is made, a small drop of 
the mixture is removed from the tube and examined microscopic- 
ally in the usual manner. In order to insure accurate dilutions, 
a graduated pipette is needed for measuring the blood and the 
culture, for the drops of both liquids must be of exactly the same 
size. Either the special pipettes devised for serum testing, or the 
Thoma-Zeiss leucocytometer will prove satisfactory for this pur- 
pose. In lieu of either of these instruments a graduated pipette 
may be readily made from a bit of glass tubing, or an ordinary 
medicine dropper. 

If the liquid serum method is chosen, fifteen or twenty drops of 
blood, drawn by making a rather deep puncture, are allowed to 
flow into a narrow calibered test-tube, and set aside for a few 
minutes until coagulation has taken place. As soon as the clot 
has formed, the nose of the graduated pipette is thrust into the 
test-tube, and one drop of the fluid serum sucked up, and diluted 
with ten drops of typhoid bouillon contained in a second test-tube. 
The preparation for microscopical examination is then made from 
this dilution. If the requisite apparatus is at hand the serum may 
be obtained by centrifugalization. 

If the macroscopical method is employed, the whole procedure 
must be carried out under the strictest aseptic precautions, for 
otherwise the growth of contaminating bacteria may interfere with 
the reaction, owing to the length of time required for the comple- 
tion of the experiment. 

The blood from which the serum is obtained is aspirated from 
one of the superficial veins of the arm, according to the technique 
employed in bacteriological examinations, and then immediately 
expelled into a sterile test-tube, which is plugged with cotton, and 
set aside until clotting occurs. If it is desired to send the speci- 
men any distance, the blood may be drawn up into a glass bulb, 
previously sterilized by heat, and then sealed at both ends. Blood 



324 



GENERAL HEMATOLOGY. 



collected in this manner will preserve its agglutinative properties 
and remain sterile indefinitely. 

Having thus obtained the serum from the whole blood, the 
test is carried out by adding the serum in definite dilutions to 
either a twenty-four-hour-old bouillon culture of the typhoid 
bacillus, or to sterile bouillon inoculated with a typhoid culture 
at the time of the test. 

In the first instance a 1:10 dilution of serum and twenty-four- 
hour typhoid bouillon is made in a sterile test-tube, which is then 
plugged, and placed in an incubator, where it remains for about 
twelve hours, at a temperature of 37 ° C. At the expiration of 
this time a positive reaction may be recognized by the presence 
of dense, whitish, flaky masses (composed of large clumps of ag- 
glutinated bacteria), forming in the typical positive reaction a thick 
precipitate at the bottom of the test-tube, which contrasts with 
the perfectly clear appearance of the supernatant bouillon. If 
the reaction is negative, the tube shows simply the uniform cloudi- 
ness of an ordinary typhoid bouillon culture. 

In the second instance a 1:10 dilution of serum and sterile 
neutral peptone bouillon is made, the mixture then being inocu- 
lated with a small loopful of typhoid bacilli derived either from a 
bouillon or an agar culture. The contents of the test-tube are 
then thoroughly mixed, and the preparation incubated at 37 0 C, 
for twenty-four hours. A positive reaction is characterized after 
this length of time by the formation of a similar grayish-white 
precipitate at the bottom of the tube, underlying an unclouded 
layer of fluid. In negative reactions the typical cloudiness of the 
typhoid growth is diffused throughout the bouillon. 

In both of these macroscopical methods control tubes of normal 
serum and typhoid bouillon should invariably be prepared, and 
incubated side by side with the specimen of serum to be tested. 

Both tests may be carried out at ordinary room temperature, 
but more certain and more typical results are obtained when the 
tubes are incubated at a temperature of 37 0 C. 

The Choice of a Method. The choice between the four methods 
of serum testing described above must depend largely upon the 
circumstances under which the test is to be made. 

The dried blood method, as already remarked, is best adapted 
to Health Board necessities, where samples of blood are collected 
by the general practitioner and sent by mail to the laboratory. 
The chief objection to this method is the impossibility in many 
cases of making accurate dilutions, since usually it can only be as- 
sumed that a given crust of blood represents the same volume in its 
liquid state as the drop of culture with which it is diluted. If the 



ENTERIC FEVER. 



325 



examiner collects the specimens himself, quite accurate dilu- 
tions may be obtained if a graduated pipette or a platinum loop 
of fixed size is used to measure both the blood and the culture. 
Another drawback is the fact that more or less typical agglutina- 
tion occasionally occurs with non-typhoid blood, although John- 
ston believes that this source of error may be always eliminated 
by using cultures of sufficient attenuation. 

In hospital work either the fluid blood or fluid serum should 
be chosen, for exact dilutions may be made by these methods, 
and if the test is made within a reasonable length of time after the 
dilution, bacterial contamination need not be feared. The writer, 
in the early days of serum testing a warm advocate of Johnston's 
method, has now discarded it wherever possible in favor of the 
more accurate and equally simple test performed with the fluid 
whole blood, or serum. 

The macroscopical method with fluid serum is too slow, and 
requires too elaborate bacteriological apparatus ever to be adopted 
for general clinical use. At present it is chiefly used by a few 
British and Continental observers in experimental work, but has 
not found popularity in this country. 

Value of the Serum Test. Fully 95 per cent, of all typhoids give 
a positive reaction at some period of the disease, usually as early 
as the eighth day, as nearly as it is possible to compute this period. 
An error of about 3 per cent, must be allowed for, on account of 
the occurrence of positive or misleading results with non-typhoid 
blood. The statistics of the Philadelphia Bureau of Health are 
of interest in demonstrating the usefulness of the test in routine 
public health work. The report for 1 898 1 shows that 5,293 
specimens from 4,597 cases diagnosed enteric fever were tested 
by the dried blood method, with a discrepancy of 5 per cent, be- 
tween the laboratory and the clinical diagnosis ; while the report 
for 1 899 2 shows that the discrepancy was only 3.9 per cent., 
based on the examination of 5,350 samples of blood from 4,483 
suspected cases. In 1900 3 3,205 specimens from 2,745 suspected 
cases were examined, with a discrepancy of 7. 1 per cent, between 
the clinical and the laboratory findings. 

In some instances repeated negative results are found until con- 
valescence is well established, and, rarely, cases are encountered 
in which the reaction never occurs at any time during the entire 
course of the illness. The blood may lose its clumping powers 

1 A. C. Abbott: Annual Report of the Division of Bacteriology, Pathology, and 
Disinfection of the Philadelphia Bureau of Health, 1899, p. 199. 
2 Ibid., 1900, p. 92. 
3 Ibid., 1901, p. 107. 



326 



GENERAL HEMATOLOGY. 



at about the time of defervescence, or, on the other hand, this pe- 
culiarity may persist for months, or even years after the attack. 
This last source of error in the test may be due to the presence 
of unsuspected foci containing typhoid bacilli, but sometimes it 
is apparently independent of such factors. Before pronouncing 
upon the value of a positive reaction in the individual case, the 
occurrence of a previous attack of typhoid, and the presence of 
lesions which may be due to the Eberth bacillus (osteomyelitis, 
cystitis, arthritis, cholecystitis, etc.) must be excluded. 

The reaction may be positive on one day of the disease or for 
a series of days, and negative on the next day or succeeding days. 
Its character is apparently uninfluenced by the intensity of the 
infection, for although as a rule the reaction is usually prompt 
and marked in severe infections, it maybe just as marked in mild 
cases. A certain relationship seems to exist between the height 
of the fever and the intensity of the reaction, for the latter is 
usually most decided at the period of maximum pyrexia. 

In the light of our present knowledge of the serum test, its 
value appears to be less than its first enthusiastic advocates were 
inclined to urge. A positive reaction, obtained by a skilled 
worker whose technique as to dilution, time limit, and culture has 
been exact, is the most valuable single sign of enteric fever, al- 
though it cannot be regarded as absolutely pathognomonic. On 
the other hand, a negative result with the test is no proof of 
the absence of the disease. 

Anemia develops shortly after the beginning 
Hemoglobin of the fever, slowly and progressively increasing 
and in intensity throughout the course of the disease, 
Erythrocytes, and persisting during the early weeks of defer- 
vescence. During the first week there is little or 
no decrease in the number of erythrocytes, although the hemo- 
globin loss appears to begin coincidentally with the first manifes- 
tations of the infection. Normal erythrocyte counts are the rule 
during the first seven days, but there are few cases of typhoid 
which fail to show a hemoglobin loss amounting to at least 1 5 
or 20 per cent, during this period. Whether this early oligo- 
chromemia is due to the influence of the fever, or whether it rep- 
resents the actual prefebrile state of the patient's blood, is difficult 
to decide. By the second week the corpuscular decrease be- 
comes evident and steadily grows more and more marked as the 
disease progresses, reaching its maximum at about the end of de- 
fervescence. Thayer 1 distinguishes a slight accentuation of the 
oligocythemia between the third and fourth weeks, the decrease 

1 Johns Hopkins Hosp. Reports, 1900, vol. viii. , p. 487. 



ENTERIC FEVER. 



327 



continuing until the seventh, when a still more decided fall occurs, 
followed in the eighth week by a considerable rise. A slow rise 
in the erythrocyte curve is observed after defervescence, and, in- 
deed, sometimes before the end of the febrile stage, until by the 
end of the fourth or fifth week of convalescence the count is 
again normal. The hemoglobin, after the first week, follows the 
same general course as the erythrocytes, but its decrease during 
the early weeks is relatively greater and its regeneration slower 
during the post-febrile period. 

Thayer's analysis 1 of the blood examinations in enteric fever, 
made in the Johns Hopkins Hospital during the past eleven years, 
furnishes a striking illustration of the development of the anemia 
during the progress of the disease. Arranged according to the 
week of the fever, the following hemoglobin and erythrocyte 
averages in uncomplicated cases are shown : 



Hemoglobin. 
(165 estimates.) 

1st week, 21 estimates, 76.1 per cent. 6th week, 6 estimates, 62.1 per cent. 

2d " 51 44 72.8 44 7th " 4 " 50.5 " 

3d " 34 44 66.2 " 8th " 3 " 56.9 44 

4th "20 44 60.5 " 9th " 4 44 47.7 " 

5th 44 20 " 57.8 44 ioth 44 2 44 66.5 44 

Erythrocytes. 
(265 counts.) 



1st week, 


32 counts, 


4,9i3>3 12 


7th week, 


8 counts, 


3.309,125 


2d 44 


86 44 


4,692,428 


8th 44 


7 " 


3,652,285 


3d " 


59 " 


4,429,208 


9th 44 


6 44 


3,509.966 


4th " 


36 44 


4,222,236 


ioth 44 


1 44 


3,920,000 


5th 44 


22 44 


4,118,590 


nth 44 


1 44 


2,109,333 


6th 44 


7 " 


4,028,428 









Seventy-four typhoid patients, both with and without compli- 
cations, examined in the German and the Jefferson Hospitals, 
show the following averages, the first estimates being taken in all 
cases in which multiple examinations were made : 



Week 

1 st week, 
2d " 
3d « 



4th 
5th 
6th 
7 th 
8th 



14 cases. 
3° 
13 
6 
6 
2 
2 
1 



Hemoglobin. 

77.4 per cent. 
66.5 

58.8 << 

49.6 " 

53-i " 

47-5 " 

47-5 " 

40.0 " 

1 Loc. cit. 



Erythrocytes. 

4,789,285 per cb. mm. 
4,161,233 " 

3>555> 000 " 

3>49°> 8 33 " 

2,445,000 " 

3,165,000 " 

3>335>°°° " 
2,790,000 " 



328 



GENERAL HEMATOLOGY. 



As a rule, the degree of a typhoid anemia is parallel to the 
severity of the attack, but this is not invariably true, since a 
mild case may be associated with a most intense anemia. In 
the series included in the last tabulation the most marked instances 
of anemia showed hemoglobin and erythrocyte estimates of 40 
per cent, and 1,720,000, 40 per cent, and 1,850,000, and 50 per 
cent, and 1,800,000, respectively. The most striking example of 
oligochromemia showed a hemoglobin percentage of 20, with a 
corresponding erythrocyte count of 2,470,000. Considerably 
lower estimates than these have been reported by a number of 
other observers, but they are uncommon. 

The effects of the cold tub, and of excessive diarrhea and 
sweating may cause a temporary polycythemia from concentra- 
tion of the blood, and these sources of high counts must be ex- 
cluded in making examinations during the early weeks of the 
disease. In four cases examined by the writer to determine the 
effects of the cold plunge, it was found that the average ery- 
throcyte increase after the bath amounted to 813,000 corpuscles 
per cubic millimeter, and the hemoglobin gain to 8 per cent. 
Hemorrhages, if severe, may cause an abrupt fall in the erythro- 
cyte count, often succeeded by a more or less successful attempt 
at regeneration, in an effort to compensate for the blood loss. 

Qualitatively, the cells show no peculiar changes, poikilocytosis, 
irregular staining affinities, and deformities of size occurring in 
relation to the intensity of the anemia. Erythroblasts are com- 
paratively rare, being absent or few in number in the average case. 
Normoblasts may be found in cases with high-grade anemia, and 
as a sequel to hemorrhage. Megaloblasts are very rare, an oc- 
casional cell of this type being observed now and then only in 
severe cases. 

A steady, slow decrease in the number of leu- 
Leucocytes. cocytes becomes evident after the first week of the 
fever, the lowest counts being found during the 
fifth or sixth week, after which an increase, which may be either 
permanent, or transient and followed by a still more decided 
leucopenia, is observed. It appears that the latter change ac- 
companies cases with severe post-febrile anemia, although suf- 
ficient data are lacking to justify absolutely positive conclusions 
on this point. In uncomplicated cases the normal count becomes 
reestablished by about the fourth week of convalescence. The 
leucopenia of typhoid corresponds in a general way to the severity 
of the attack, and although not marked in the average, in the 
individual case it may be striking, counts of from 2,000 to 3,000 
being not at all uncommon. 



ENTERIC FEVER. 



329 



Thayer's report of 832 counts in uncomplicated cases shows 
the following range of the leucocytes, according to the week of 
the disease : 



1 st week, 


119 counts, 


6,442, 


8th week, 14 counts, 


6,6l4 


2d " 


258 " 


6,251, 


9th " 


7 




5^57 


3d « 


200 " 


5.528, 


10th " 


2 


< * 


5,000 


4th " 


117 " 


5A3*> 


nth " 


3 


< < 


5^333 


5th " 


70 " 


5>5 IO > 


12th " 


2 


« < 


5,000 


6th " 


25 " 


5> 6 9°> 


13th « 


1 




8,000 


7th " 


14 " 


6,132. 











The leucocyte estimates of the 74 hospital typhoids referred to 
above averaged : 



1 st week, 


14 cases, 


8,026 leucocytes 


per cb. 


2d " 


30 << 


6,713 


( e ( 


3d « 


13 " 


7,076 


( ( t 


4th " 


6 " 


4,400 lt 


i ( 1 


5th « 


6 <f 


5,766 


1 ( 1 


6th " 


2 " 


6,250 


a i 


7th " 


2 {f 


4,5°° " 


( C ( 


8th " 


1 " 


8,000 " 


1 1 t 



Disregarding the week of the fever, the number of leucocytes 
in these cases ranged as follows : 

Above 10,000 in 7 cases. 

From 9,000—10,000 " 3 " 

" 8,000- 9,000 " 8 " 

" 7,000- 8,000 " 14 " 

" 6,000- 7,000 " 8 " 

" 5,000- 6,000 " 10 " 

" 4,000— 5,000 " 11 " 

" 3,000- 4,000 " 8 " 

" 2,000- 3,000 " 4 " 

" 1,000- 2,000 " 1 11 

Highest: 16,000 per cb. mm. 

Lowest: 1,333 " 

Average : 6, 706 " " 

It appears from these figures that counts in excess of 10,000 
per cubic millimeter may be looked for in more than 10 per 
cent, of all cases, such an increase being due either to the effects 
of blood concentration from diarrhea, sweating, vomiting, or cold 
tubbing, or to some hidden or frank complication. In 4 of the 
7 relatively high counts above noted, the cause was plain — 
croupous pneumonia in 2, cholecystitis in 1, and furunculosis in 



33° 



GENERAL HEMATOLOGY. 



r. In the other 3, all of which were made in patients whose 
fever had not yet run seven days, the factors of the increase were 
undetermined ; possibly it was due to physiological blood in- 
spissation. 

Inflammatory complications, such as otitis, abscess, pneumonia, 
severe bronchitis, peritonitis, cystitis, periostitis, and phlebitis give 
rise to a prompt leucocytosis in patients whose vital powers are 
sufficiently strong to react against the process. Intestinal hemor- 
rhage is usually followed by an increase reaching its maximum 
within twenty-four hours after the blood loss, and disappearing 
within a week. Intestinal perforation may be promptly followed 
by a leucocytosis, the increase developing within a few hours. 
Thayer has observed that in some instances the increase in the 
number of leucocytes succeeding the perforation may tend to 
diminish and disappear with the aggravation of the symptoms, 
and that not infrequently there is a complete absence of leucocy- 
tosis and sometimes a diminution in the number of leucocytes 
after this accident. He also considers that the prospect of relief 
by surgical interference is best in those cases with a leucocytosis, 
the absence or disappearance of this sign following a perforation 
being an indication of the malignancy of the infection or the pros- 
tration of the patient. 

Qualitative changes are absent or inconspicuous during the 
first two weeks of the fever, but during the third week a slow, 
progressive decrease in the relative percentage of polynuclear 
neutrophiles, with a consequent increase in the mononuclear un- 
granulated forms, begins, this change becoming most marked at 
about the end of defervescence. In 23 of the writer's cases the 
percentage of polynuclears averaged, according to the week of 
the disease, 75.0 per cent, for 8 cases in the first week; 70.9 
per cent, for 7 in the second week ; 50.2 for 4 in the third week ; 
60.0 per cent, for 2 in the fourth week ; and 64.0 and 68.0 per 
cent, for a single case in the fifth and sixth weeks, respectively. 

Thayer has found that the mononuclear cells which are most 
markedly increased are " elements containing nuclei not much 
larger than those of lymphocytes, and often presenting the gen- 
eral appearance of a lymphocyte nucleus, with the exception of 
the slight affinity for coloring matters. The size of these cells is 
usually about that, or but little larger than that of the ordinary 
polymorphonuclear neutrophile." The typical small lymphocyte, 
and the " transitional " forms undergo little or no increase. 

The eosinophiles are almost invariably decreased, both abso- 
lutely and relatively, and are often absent during the active 
febrile stages. The relative percentages of these cells in the 



ENTERIC FEVER. 



331 



above cases averaged 0.87, rising as high as 5 per cent, in only 
2 cases, and being entirely absent in 11. 

Myelocytes in small numbers may be found in severe forms 
of post-typhoid anemia, but they are absent during the active 
period of the infection. Turk's "stimulation forms" are met 
with under the same conditions. 

Thayer's elaborate report of the Johns Hopkins Hospital cases 
includes the following averages of the differential leucocyte counts : 



Week. 


Small Mono- 
nuclear. 


Large Mono- 
nuclear 


Polynuclear 
Neutrophile. 


Eosinophile. 


1st week, 


12 counts. 


12-9% 


12-4% 


74-o% 


0.5% 


2d " 


39 " 


I4.6 


13.4 


70.9 


0.8 


; 3d " 


34 " 


21.5 


11. 6 


66.3 




4th " 


19 « 


20.I 


14.4 


65.0 


O.4 


5th " 


8 " 


18.2 


19.7 


61.7 


0,3 


6th " 


4 " 


22.6 


13-5 


57-7 


6.0 


7th " 


1 " 


23-7 


34-4 


37-3 


4-6 


8th " 


1 " 


24.2 


16.8 


56.9 


2.1 



According to Hayem, 1 the number of blood plaques is markedly 
decreased during the febrile period of the fever, as in any other 
condition characterized by pyrexia. 

The blood examination furnishes three clinical 

Diagnosis. signs of positive value in the diagnosis of enteric 
fever : the serum reaction ; a subnormal leuco- 
cyte count or at least an absence of leucocytosis ; and in cases 
with roseola the detection of the Eberth bacillus by spot cultur- 
ing. The influence of complications upon the behavior of the 
leucocytes must, however, always be borne in mind. 

Malarial fever, acute miliary tuberculosis, cerebrospinal menin- 
gitis, certain atypical cases of pneumonia and influenza, and septi- 
cemic and pyemic processes, such as ulcerative endocarditis, are 
the diseases most frequently confounded with typhoid, and in their 
differentiation the blood report often gives just the essential clue. 

Malarial and enteric fevers are both associated with an absence 
of leucocytosis, but in the former the presence in the blood of the 
malarial parasite and pigment is sufficiently conclusive. Acute 
miliary tuberculosis, if a pure infection, also shows a similar 
absence of a leucocyte increase, and in excluding this disease 
reliance must be placed on the Widal test ; should this prove nega- 
tive, attempts may be made to culture specific bacteria from the 
blood. Influenza is not characterized by leucocytosis, and must be 
differentiated from typhoid by the aid of the serum test. Cerebro- 



1 "Du Sang," etc., Paris, 1889. 



332 



GENERAL HEMATOLOGY. 



spinal meningitis, pneumonia, and septic and pyemic conditions 
may be differentiated by their association with a more or less 
well-marked leucocytosis. In the last-named processes bacterio- 
logical examination of the blood not infrequently gives conclusive 
results. 

XVII. ERYSIPELAS. 

In severe infections Turk 1 has noted a de- 
General cided increase in the quantity of fibrin and in the 
Features. number of blood plaques, but in the case of average 
severity these changes are not to be observed. 
Drouin 2 has found that the alkalinity of the blood is greatly de- 
creased. Negative results from bacteriological examination of the 
blood are the rule. 

Moderate anemia, characterized by a some- 
Hemoglobin what disproportionate hemoglobin loss, is com- 
and mon in the severer forms of the disease, but not 
Erythrocytes, in mild cases. The decreases are not notable, 
amounting on the average to a loss of not more 
than io or 20 per cent, of corpuscles and of about 30 per cent, 
of hemoglobin. Maragliano's degenerative changes of corpus- 
cular structure have occasionally been found. 

Leucocytosis of the polynuclear neutrophile 
Leucocytes, type is the usual finding, but mild cases fre- 
quently run their course without provoking the 
slightest increase. Except in isolated instances, the leucocytosis 
is not high, the counts usually being about 15,000, and rarely 
more than 20,000 cells to the cubic millimeter. Von Limbeck, 3 
and Chantemesse and Rey 4 have shown that the leucocyte and 
temperature curves maintain a definite parallelism in the majority 
of cases, and that the diminution in the leucocytosis as a rule 
anticipates the fall in temperature. There is, however, no appa- 
rent relationship between the height of the leucocytosis and the 
degree of pyrexia, for moderate leucocytoses are not incompatible 
with strikingly high temperatures. It is generally agreed that 
the highest counts are found in the severest cases, provided that 
the patient's resisting powers are acting normally. An exten- 
sion of the lesion is generally accompanied by an increase in 
the leucocytosis. 

With the onset of convalescence, as the leucocytosis disappears 
the normal percentages of the different forms of leucocytes, dis- 

1 Loc. cit. 

2 These de Paris, 1892, n. 83, p. 108. 

3 Loc. cit. 

4 Presse med., 1899, vol. vi., p. 316. 



FEVER. 



333 



turbed during the febrile period, are reestablished by a rapid 
increase in the small lymphocytes and eosinophiles, and a decrease 
in the polynuclear neutrophiles ; the percentage of large lympho- 
cytes remains stationary, and the eosinophiles are absent during 
the height of the attack, according to Chantemesse and Rey. 
Small percentages of myelocytes and an occasional " stimulation 
form" are commonly found during the active stages of the leuco- 
cytosis. 

XVIII. EXOPHTHALMIC GOITRE. 

There are no characteristic changes in the hemoglobin and 
erythrocytes, although an anemia indistinguishable from typical 
chlorosis is not an infrequent feature. Such cases must be dis- 
tinguished from so-called "thyroid chlorosis," or chlorosis with 
thyroid hypertrophy, by means of other clinical symptoms. It 
seems likely that in cases of Grave's disease characterized by 
excessive diaphoresis, emesis, and diarrhea, the blood concen- 
tration thus produced may be sufficient more or less effectually 
to obscure the real grade of anemia existing. 

The leucocytes are not increased in number, and leucopenia of 
a decided degree is frequently observed. Relative lymphocytosis 
is a common change, and moderate increase in the percentage of 
eosinophiles an occasional finding. 

XIX. FEVER. 

It is a well-recognized fact that more or less hemoglobin and 
erythrocyte losses follow pyrexia maintained for any length of 
time, but an attempt to demonstrate the exact cause or group of 
causes of this anemia involves the analysis of a most complex 
problem in physiology, about which the most skilled investigators 
express diametrically opposite opinions. Some maintain that suffi- 
cient actual destruction of the corpuscles occurs as the result of 
fever to account for their decrease in number, while others attrib- 
ute the loss largely, if not wholly, to the influence of vasomotor 
changes. Maragliano 1 has shown that capillary contraction ac- 
companies the period of active pyrexia, while Reinert 2 suggests 
that the blood is diminished in volume by the excessive drain 
upon the body fluids occurring at this time. In septic fevers, 
furthermore, additional inspissation of the blood is produced by 
the influence of bacteria and their products. These factors tend- 
ing to inspissate the blood favor the production of polycythemia, 
which change is to be observed during the stage of active fever. 
But as defervescence sets in the conditions are reversed, for the 

1 Berl. klin. Woch., 1887, vol. xxiv , p. 797. 

2 " Die Zahlung der roten Blutkorperchen." Lepzig, 1891. 



334 



GENERAL HEMATOLOGY. 



capillaries then dilate, the draining away of the fluid elements of 
the blood ceases, and, consequently, dilution of the blood now 
occurs. Anemia therefore develops coincidentally with the dis- 
appearance of the fever. It is undetermined whether this post- 
febrile anemia is the result purely of these physical causes, or of 
these causes plus a certain amount of real hematocytolysis due 
to high temperature. It seems reasonable to regard both factors 
as active. 

Coagulation and fibrin behave so erratically that no definite 
statements regarding them are justified. In the incipient stage 
of septic fevers coagulation is much delayed, according to 
Schmidt, 1 but during the later stage it occurs more rapidly than 
normal. The leucocytes in this class of fevers are generally 
increased in number. 

The alkalinity of the blood undergoes wide variations in differ- 
ent febrile states, but it cannot be said that these changes, which 
are probably due to complex chemical processes rather than to 
the primary effect of the fever, are constantly parallel, either to 
the degree of pyrexia or to the behavior of the leucocytes. 
Lowy and Richter 2 state that increased alkalinity occurs co- 
incidentally with the stage of hypoleucocytosis — a statement 
which Strauss, 3 Lowit, 4 and others have verified. Fodor and 
Rigler's experiments 5 have proved that the pyrexia following 
infection with pathogenic bacteria ultimately effects a diminution 
in the alkalinity of the blood, and that this change is sometimes 
preceded by a distinct primary increase. The conclusions voiced 
by von Jaksch, 6 Kraus, 7 and other earlier writers, that decreased 
alkalinity is a constant accompaniment of febrile processes, can- 
not be unreservedly accepted if von Limbeck's 8 later statements 
to the contrary are to be believed. 

XX. FILARIASIS. 

Filariasis, the pathological condition depend- 
Occurrence. ing upon the presence in the body of the parental 
and embryonic forms of the filaria sanguinis 
hominis, is of widespread distribution throughout the tropics and 
subtropics, being prevalent in various districts of Africa, India, 

^fliiger's Archiv., 1875, vol. xi., pp. 291 and 515. 
2 Deut. med. Woch., 1895, vol. xxi. , p. 526. 

3 Zeitschr. f. klin. Med., 1896, vol. xxx., p. 315. 

4 "Die Lehre v. Fieber," Jena, 1897. 

5 Centralbl. f. Bakt. u. Infect., 1897, vol. xxi., p. 134. 
6 Zeitschr. f. klin. Med., 1887, vol. xiii., p. 380. 
7 Zeitschr. f. Heilk., 1889, vol. x., p. 106. 
8 Centralbl. f. inn. Med., 1895, v °l- xy i-> P- ^49- 



FILARIASIS. 



335 



Australia, China, Japan, South America, and the islands of the 
South Pacific and the West Indies, and, as mentioned below, hav- 
ing been found to a limited extent in North America. 

Six distinct species of embryo blood worms, 
Parasitology, the parental forms of which do not enter the cir- 
culation, have been demonstrated in the periph- 
eral blood of man, these parasites being known by the general 
term, filaria sanguinis hominis. These different filarial, according 
to the nomenclature suggested by Manson, 1 are distinguished by 
the names filaria nocturna ? filaria diuma, filaria perstans , filaria 
Demarqnaii, filaria Ozzardi, and filaria Magalhaesi. To but a 
single member of this group, the filaria nocturna, has an undis- 
puted pathological role been assigned, this parasite being regarded 
as the cause of various forms of lymphangitis, of lymph varices, 
of lymph scrotum, of tropical elephantiasis Arabum, of endemic 
chyluria, of chylous ascites, and of other tropical diseases of more 
or less obscure nature. The filaria persta7is, Manson conjectures, 
may possibly be the etiological factor of that peculiar West African 
disease known as negro lethargy, or the " sleeping sickness " of 
the Congo, as well as of a form of African kra-kra, or " craw- 
craw." Further study of this subject is necessary, however, be- 
fore these relationships may be unreservedly credited. The other 
filariae {diufna, Demarquaii, Ozzardi and Magalhaesi ) possess no 
interest from a diagnostic standpoint, since their life history and 
pathological significance are still obscure. 3 

This is by far the most important member of 
The Filaria the above-named class of blood worms, being the 
Nocturna. one most familiarly known of all, as well as the 
one of greatest clinical interest, because of the 
interesting pathological lesions which it is capable of exciting. 
In this country cases of filariasis due to the filaria nocturna have 
been reported by a number of different observers, Guiteras, 4 de 
Saussure, 5 Mastin, 6 Slaughter, 7 F. P. Henry, 8 Dunn, 9 and Lothrop 

1 ''Tropical Diseases," N. Y., 1898. 

2 The author is greatly indebted to Dr. F. P. Henry and to Dr. J. H. Gibbon for 
the opportunity of making repeated blood examinations in two cases of filaria noc- 
turna infection occurring in their respective hospital services. 

3 For a complete description of filariasis and of the various forms of the filariae the 
reader should consult Manson' s article in Davidson's " Hygiene and Diseases of the 
Warm Climates" (Edinburgh, 1893), or this author's text-book to which reference is 
made above. 

4 Med. News, 1886, vol. xlviii., p. 399. 

5 Med. News, 1890, vol. lvi., p. 704. 

6 Annals of Surg., 1888, vol. viii., p. 321. 

7 Med. News, 1891, vol. ii., p. 649. 

8 Med. News, 1896, vol. xviii., p. 477. 

9 Trans. Coll. of Phys. of Phila., 1898, p. 80. 



336 



GENERAL HEMATOLOGY. 



and Pratt, 1 having met with the disease. A few of these cases 
have been regarded by their reporters as indigenous, but the 
great majority of them, it is safe to state, were directly imported 
from the tropics. To the writer's knowledge, at least three cases 
have been diagnosed in Philadelphia during the last four years. 

Fig. 45. 




The filaria nocturna. 
From a photomicrograph of the parasite in fresh blood. 



As may be inferred from the name, the embryos of the filaria 
nocturna are found in the peripheral blood most abundantly at 
night, the vast majority of the parasites retiring into the deeper 
circulation during the daytime. From late in the afternoon 
until about midnight they make their way into the peripheral 
vessels in progressively increasing numbers, with more or less 
fluctuation, the maximum number being found at the latter time, 
after which they begin to grow less and less numerous, until by 
about eight o'clock in the morning they have practically all dis- 
appeared from the superficial circulation and reentered the deeper 
vessels in which they remain until the close of the day. This 
peculiar periodicity is well illustrated by a recent series of inves- 
tigations made by Lothrop and Pratt, 2 who have charted the 
phenomenon in one case, showing the approximate number of 
parasites to the cubic millimeter of blood as follows : 4 p. m., 
100 ; 6 p. m., 275 ; 8 p. m., 1,300 ; 10 p. m., 900 ; 12m., 1,500 ; 
2 a. m., 700 ; 4 a. m., 900 ; 6 a. m., 125 ; 8 a. m., 125 ; and 10 

^m. Journ. of Med. Sc., 1900, vol. cxx., p. 525. 
2 Loc. cit. 



FILARIASIS. 



337 



a. m., 100. Twenty-one hundred embryos per cubic millimeter 
was the highest number ever observed by these authors, the 
specimen in which this count was made having been taken at 
midnight. This characteristic periodicity, it should also be re- 
marked, is completely reversed if the individual harboring the 
parasite reverses his habits of life, by sleeping' during the day and 
moving about at night ; if such should be the case the worms will 
appear in the peripheral blood during the daytime, the patient's 
period of rest, and seek the deeper circulation at night, the pa- 
tient's period of activity. 

• The painstaking studies of Manson, to whom we owe most of 
our knowledge of the filaria's life history, have shown that the 
mosquito is the intermediate host of this parasite, which may be 
found alive in the stomach of this insect after it has fed upon a 
filarious individual. Ecdysis takes place in this organ, and the 
embryos, after having cast their sheaths, manage eventually to 
penetrate the thoracic muscles of their host, in which situation 
they undergo a developmental phase lasting for about seven days. 
The mosquito, gorged with these partly mature parasites, seeks 
a stagnant pool upon the surface of which she lays her eggs, and 
then having died, falls, herself, upon the water. The filariae then 
escape from the corpse of their late host, and thus, through the 
medium of drinking water, may gain access to the stomach of 
human beings. Having been swallowed by man, they penetrate 
the stomach wall and other tissues, and ultimately reach some 
part of the lymphatic system in which they lodge, sexually ma- 
ture, fecundate, and beget the innumerable embryos which enter 
the lymph stream, and in course of time find their way into the 
circulating blood. 

Appearance in Fresh Blood. In the unstained blood-film the 
parasite appears under the microscope as a long, slender, graceful 
worm possessing a most remarkable degree of activity. It measures 
about 1/80 of an inch in length, and 1/3,000 of an inch in diam- 
eter, and is of a pearly-gray color, with perhaps the faintest sug- 
gestion of a yellowish tone, in certain lights. Its general appear- 
ance conveys to one, at first glance, the impression of a thin, 
transparent tube through which a rapidly flowing stream of liquid 
is constantly circulating. The head (cephalic end) is gracefully 
rounded, while the tail (caudal end) gradually tapers for about 
one-sixth the entire length of the animal, and ends in a fine-pointed 
extremity. The worm is cylindrical in shape, of regular outline, 
and consists of a central body enveloped in a distinct, loosely 
fitting, hyaline, structureless sheath, which is about as much too 
large for the body as the thumb of an adult's glove would be for 
22 



338 



GENERAL HEMATOLOGY. 



the little finger of a child. Thus, that part of the sheath tem- 
porarily unoccupied by the body is prone to collapse, folding upon 
itself and trailing after the worm at either or both extremities, as 
a twisted, whip-like ribbon. The greater part of the body appears 
to be of a homogeneous structure when examined in the freshly 
prepared slide, but after the specimen has been kept for several 
hours coarse granulations begin to stipple its surface, first develop- 
ing in the center, and gradually spreading toward the periphery. 
(See Fig. 46.) A series of fine striations, like the milling on a 



Fig. 46. 




FiLARIA NOCTURNA. 

Showing beginning granular degeneration of the body of the parasite. 

coin, may be observed running along both edges of the body, at 
right angles to its long axis. A viscus, appearing as a mass of 
granular material, occupies a part of the central third of the worm's 
body, running parallel to its long axis. Upon careful examination 
with an oil-immersion objective, rhythmical dimpling or puckering 
movements may generally be observed at the tip of the cephalic 
end of the embryo ; these movements, which occur with more or 
less regularity at the rate of from twenty-five to forty times a 
minute, have been attributed to the act of respiration. As the 
wriggling of the worm becomes less active, close observation will 
show that these pouting movements are caused by the alternate 
covering and uncovering of the cephalic end by a delicate six- 



FILARIASIS. 



339 



lipped prepuce. The sudden projection and the equally rapid 
retraction of a filamentous fang or tongue-like organ from the 
worm's uncovered head may also be noted in some instances, but 
this characteristic is so difficult to make out that it may usually 
be looked for in vain. At a point about one-fifth of the entire 
length of the worm posterior to the head it is possible to make 
out a triangular, slightly luminous patch, shaped like the letter V, 
this spot being known as the V-shaped patch, regarded by Man- 
son as a rudimentary generative organ. A second spot, some- 
what similar to it in appearance but smaller in size, may occasion- 
ally be seen at a point just above the tail of the parasite ; this 
spot Manson is inclined to regard as the rudimentary anus. 

The movements of the worm are rapid and violent in the ex- 
treme, so much so that they are followed with difficulty with any 
but a low-power dry objective. The parasite is never at rest : 
one moment it may be curled up into a tight bunch, like a coil 
of rope ; the next moment it may suddenly straighten out and 
become rigid for an instant, only again to resume its incessant 
contortions and twistings which throw it into every conceivable 
sort of shape. If particular attention is paid to the point, it will 
be noticed that, however rapid and complicated may be its 
movements, the parasite is never seen to turn completely over, 
laterally. The accompanying series of sketches, of the jilaria 
nocturna in a fresh blood slide, illustrate a few of the differ- 
ent forms which this parasite may assume? (Fig. 47.) The 
worm seems to move about among the blood corpuscles with 
graceful and quick undulations of its body and abrupt whip- 
like strokes of its tail, butting its head against the more re- 
sisting masses of cells or else seeking a less difficult passage 
around them, always in motion but never, it appears, with any 
definite aim to its exertions. Contrary to the views expressed 
by most observers, that the movements of the Jilaria nocturna 
are not truly propulsive in character, the writer has repeatedly 
noticed that this worm sometimes travels several times the dis- 
tance of the diameter of the microscope field (one-sixth-inch 
objective, one-inch ocular, and 160 mm. tube-length), although 
in most cases its excursions were limited to a measured area not 
exceeding half-a-dozen square micromillimeters. It cannot be 
denied that these apparently progressive movements of the worm 
may possibly be due to the currents in the blood plasma, but they 
certainly seem to have every characteristic of a true locomotive 
force. After the slide has been kept for a few hours the move- 
ments of the worm, at first so confusingly rapid, gradually become 
slower and slower, and these torpid, more deliberate turnings and 



340 



GENERAL HEMATOLOGY. 



twistings may be accurately followed under an immersion lens. 
If the parasite happens to become confined in a little pool of 
plasma surrounded by rouleaux of half-dried erythrocytes, an 
accident which often happens when the drying of the film has 



Fig. 47. 

9.46 948 9 SO 





9.52 



9.58 



/0 02 




Showing the changes in the shape of the filaria noctukna during the period of 
half an hour. the sketches, made at two-minute intervals, all represent the same 
parasite. 

spread inward some little distance from the edges of the cover- 
glass, its finer structure and characteristics may be studied with 
great ease and accuracy. 

The phenomenon of ecdysis, or shedding of the worm's sheath, 
with the consequent escape of its naked body into the plasma, 
occurs when slides containing the live filarial are kept for some 
hours in a cold (not freezing) place. It commonly happens that 
just before the death of the parasite an occasional erythrocyte or 
leucocyte becomes tightly adherent to the sheath, swinging to 
and fro with the now lazy, torpid movements of the animal. 

Technique of Examination. A rather large drop of finger 
blood, taken from the patient late in the evening, preferably 
toward midnight, is placed between a slightly warmed slide and 
cover-glass the edges of which are immediately sealed with 



FILARIASIS. 



341 



cedar-oil or with vaseline. The parasite should be searched for 
with a low-power dry objective, a two-thirds-inch lens being most 
useful for this purpose, and the attention of the examiner directed 
especially to portions of the field which may show any unnatural 
agitation of the blood cells. In specimens prepared in this man- 
ner the filarise will usually remain active for several days, gener- 
ally for at least forty-eight hours, and sometimes for a longer 
period, as in Henry's 1 experience, this author having kept them 
alive for ten days in a cold room. 

Staining the Filarice. Films fixed for fifteen minutes in equal 
parts of absolute alcohol and ether, and stained with thionin 
give the clearest-cut pictures, the multitude of small nuclei which 
crowd the body of the filarise being sharply differentiated by the 
use of this dye. Fixation by heat or by formalin cannot be 
employed without risk of injuring the finer structure of the em- 
bryo. Fair results may also be obtained by staining with methy- 
lene-blue, or with Jenner's stain, but the definition is not nearly 
so satisfactory with these dyes as it is with thionin. The technique 
suggested by Manson 2 (washing out the hemoglobin of the 
erythrocytes with water, drying, fixing in alcohol, and staining 
with methylene-blue or with hematoxylin) has usually proved 
unreliable in the writer's hands. The same comment may be 
made regarding attempts to demonstrate the structure of the 
worm by staining with fuchsin, as recommended by certain 
authors. 

The presence in the circulation of the filaria 
Hemoglobin nocturna does not appear of itself to be a factor 
and in the production of any conspicuous changes in 
Erythrocytes, the erythrocytes and their hemoglobin equivalent, 
if the limited data at present available may be 
taken as criteria. The high-grade anemia sometimes associated 
with filariasis, mentioned by Ehrlich and Lazarus, 3 is due, no 
doubt, to such complications as hematuria, severe chyluria, and 
chronic diarrhea. The following counts in three cases, the first 
two made by the author, the third by Lothrop and Pratt, 4 may 
be taken as representative for the average case : 

Hemoglobin. Erythrocytes. 

Case I. 88 per cent. 4,876,000, per cb. mm. 

" II. 85 " 4,200,000 " " 

III. 93 " 6,016,000 " " " 

1 Loc. cit. 

2 Loc. cit. 

3 Loc. cit. 

4 Loc. cit. 



342 



GENERAL HEMATOLOGY. 



Neither structural changes, nor irregular staining affinities of 
the cells, nor the occurrence of nucleated erythrocytes have been 
reported in connection with the disease. 

The number of leucocytes does not exceed the 

Leucocytes, physiological limits of health, except as the re- 
sult of some complication. Thus, in the first 
case quoted above the leucocyte count was found to be 41,000 
per cubic millimeter, but this increase was regarded purely as a 
post-operative rise, the patient having been operated upon for a 
supposed varicocele less than twenty-four hours before the blood 
examination was made. The count in the second case was 8,000, 
and in the third the counts were 8,000, 7,400, and 3,500, respec- 
tively — an average of 6,300. 

The relative percentage of mononuclear non-granular leuco- 
cytes is somewhat higher than normal, with a consequent decrease 
in the proportion of polynuclear neutrophiles. The eosinophiles 
either remain at a maximum normal percentage or may be dis- 
tinctly in excess of this figure. In Case II. the actual number of 
these cells to the cubic millimeter of blood was estimated at 766, 
the percentage being 9.5. In this same case it was also observed 
that the great majority of lymphocytes appeared as cells having a 
deeply stained eccentric nucleus surrounded by an abnormally 
large area of protoplasm, the general appearance of these cells be- 
ing similar to those in the illustration shown on page 259. Typical 
coarsely granular mast cells may be found in small numbers or 
they may be entirely absent, as may also be the finely granular 
forms of basophiles. The presence of myelocytes has not been 
noted. 

The above qualitative changes in the leucocytes may be illus- 
trated by the following " first-counts " of the three cases men- 
tioned above : 



Forms of Leucocytes. 


Case I. 


Case II. 


Case III 


Small lymphocytes. 


23. 1 per cent. 


34. 2 per cent. 


35-33 cent. 


Large lymphocytes. 


9.0 " 


0.6 " 


3.67 


Polynuclear neutrophiles. 


63.9 « 


55-7 " 


56.67 " 


Eosinophiles. 


3-4 " 


9-5 " 


4-33 " 


Mast cells. 


0.6 " 


0.0 " 


0.0 " 


Myelocytes. 


0.0 " 


0.0 " 


0.0 " 



The detection of the filaria nocturna in the 
Diagnosis, blood serves at once to differentiate idiopathic 
from parasitic chyluria, hydrocele from lymph 
scrotum, hernia and other tumors of the groin from parasitic 
inguinal varicosities (Bancroft's " helminthoma elastica"), and 



GASTRITIS. 



343 



filarial orchitis from other inflammatory conditions of the testes. 
Non-parasitic lymphedema affecting, for example, the legs, can but 
rarely be distinguished by the blood findings from true elephan- 
tiasis Arabum, since in the latter disease it is exceptional to find 
filaria in the general circulation. 

XXI. FRACTURES. 

Blake, Hubbard, and Cabot 1 conclude, from a study of 38 
cases, that in simple uncomplicated fractures the number of leu- 
cocytes is seldom increased to any extent, a statement which applies 
also to complicated fractures in the great majority of instances. 
Of 23 simple fractures examined by these authors, in but 10 was 
the count higher than 10,500 per cubic millimeter, and of these 
only 6 exceeded 12,000. The highest estimate was 15,400, in a 
fracture of the pelvis, and the next highest, 14,800, in a broken 
leg. Of 1 5 complicated fractures, but 2 showed any decided in- 
crease in the number of leucocytes, namely, a fracture of the tibia 
and fibula, with symptoms suggestive of fat embolism, in which 
the count was 1 5,600 ; and a case of fractured ribs with injury of 
the lung, in which the leucocytes numbered 14,900 two days 
after the accident. An estimate of 5,400 cells was made in a 
compound fracture of the leg two hours after the accident. 

Lipemia is occasionally met with in fractures of the long bones 
involving injury of the fatty marrow. 

XXII. GASTRITIS. 

In the acute form there is no deviation from 
Hemoglobin normal in the number and hemoglobin value of 
and the erythrocytes, except in the event of hyper- 
Erythrocytes. emesis, which, through concentration of the blood, 
may cause a transient polycythemia. In the 
chronic form secondary anemia frequently develops, and occasion- 
ally reaches an extreme grade, should the gastric lesion be suffi- 
cient to interfere radically with the digestion and absorption of 
food. In instances of this sort the quantitative changes may 
simulate those of true pernicious anemia, but the qualitative 
changes typical of this disease are invariably wanting. In pass- 
ing, it seems pertinent to recall the etiological relationship, dis- 
tinguished by some authorities, between gastric tubule atrophy 
and pernicious anemia. In cases associated with gastrectasis 
and hyperacidity, blood inspissation from emesis is a common 
change. 

1 Am. Surg. Assn., Baltimore, May 7, 1901. (Personal communication from Dr. 
J. B. Blake. ) 



344 



GENERAL HEMATOLOGY. 



A synopsis of J. A. Lichty's studies 1 of the hemoglobin and 
erythrocytes in 98 cases of various gastric disorders shows the 
following average values : 



Condition. 


No. of Cases. 


Hemoglobin Percentage. 


Erythrocytes per cb. mm. 


Hyperchlorhydria. 


39 


90.9 


5,556,000 


Hypochlorhydria. 


13 


83.5 


5,431,000 


Gastric achylia. 


6 


92.1 


5,68o,000 


Gastric dilatation. 


11 


85.6 


5,623,000 


Gastric neurasthenia. 


13 


87.2 


5,274,000 


Chronic gastritis. 


14 


9I.0 


5,498,000 



From other investigations, Lichty also determined that in the 
above-named diseases there is no definite relationship between 
the condition of the blood, the urine, and the gastric contents. 

In acute gastritis leucocytosis of the poly- 
Leucocytes. nuclear neutrophile type is common, although 
not constant ; the increase is most notable in the 
severest cases, but even in these the count seldom exceeds 1 5,000 
or 20,000. Hyperinosis also usually exists. In chronic cases 
an absence of leucocytosis is the rule, while leucopenia, resulting 
from defective absorption, is an occasional finding. Relative 
lymphocytosis is commonly associated with leucopenia, and 
sometimes with normal leucocyte counts. In a small proportion 
of cases digestion leucocytosis is either delayed or absent. 

The presence of a leucocytosis is a valuable 
Diagnosis, sign in ruling out ejiteric fever, should the diag- 
nosis lie between this disease and acute febrile 
gastritis. This sign, however, can not be employed to differentiate 
other acute infections, such, for instance, as appendicitis. 

The blood furnishes no sure means of differentiating chronic 
gastritis from gastric cancer, although a persistent leucocytosis is 
very suggestive of the latter ; unfortunately, digestion leucocytosis 
is neither constantly absent in cancer nor invariably present in gas- 
tritis. 

Certain cases of chronic gastric catarrh, with atrophy of the 
stomach tubules, in course of time develop a clinical picture very 
like that of true pernicious anemia, since they present not only a 
similar cachexia, but also a very striking diminution in hemo- 
globin and erythrocytes. But pernicious anemia is characterized 
by the presence of nucleated eiythrocytes the majority of which 
are megaloblasts, while in the secondary anemia of gastric catarrh 
eiythroblasts are uncommon, and if present show a predominance 
of cells of the normoblastic type. 

jPhila. Med. Journ., 1899, vol. iii., p. 326. 



GASTRIC ULCER. 



345 



XXIII. GASTRIC ULCER. 

The average case shows a loss of approxi- 
Hemoglobin mately 40 per cent, of hemoglobin, and of 
and 1 ,000,000 erythrocytes to the cubic millimeter, 

Erythrocytes, and, owing to this prevalence of a dispropor- 
tionately large oligochromemia, low color indices 
are the rule. The individual case may show a much greater 
degree of anemia, but no matter how marked the cellular decrease, 
it is always far outstripped by the diminution in the percentage of 
hemoglobin. In fact, in some instances the latter alone is subnor- 
mal, the blood condition of chlorosis being thus faithfully counter- 
feited. The average index for the cases tabulated below was 0.72. 

Profuse hemorrhage may provoke a very marked anemia, while 
protracted emesis tends to concentrate the blood, thus masking 
its real condition. 

The several degenerative changes affecting the erythrocytes, 
common to any severe anemia, may be present, if the blood 
deterioration is sufficiently profound. After a severe hemorrhage 
a few normoblasts not infrequently appear in the blood tempo- 
rarily, and an occasional cell of this type may be found at other 
times in cases with marked cachexia. 

The following summary illustrates the hemoglobin and eryth- 
rocyte ranges in 20 cases : 

Hemoglobin. Erythrocytes. 

Above 5,000,000 in 1 case. 

From 4,000,000—5,000,000 " 10 cases. 
" 3,000,000—4,000,000 " 6 " 
" 2,000,000-3,000,000 " 3 " 



Average: 57.8 % Average: 4,017,000 per cb. mm. 

Maximum: 80.0 " Maximum: 5,200,000 " " " 

Minimum: 25.0 " Minimum: 2,450,000 " " " 

Greenough and Joslin 1 report hemoglobin estimates in 73 cases, 
of which 34 were below 50 per cent., and 64 below 80 per cent. 
Of their 43 erythrocyte counts, 24 were below 4,000,000 per 
cubic millimeter, the color index for this series averaging 0.67, 
and ranging from 0.35 to 1.4 1. 

Absence of leucocytosis is the rule, for an 
Leucocytes, increase occurs only after taking food, or in the 
event of some complication such as hemor- 
rhage or perforation. But the fact must be recalled that neither of 

1 Am. Journ. of Med. Sc., 1899, vol. cxviii., p. 167. 



70-80 


% 


in 


5 


cases. 


60-70 


i ( 




6 




50-60 


(( 




1 


1 & 


40-50 


ec 


ft 


4 


t c 


30-40 


Ci 




2 


i i 


20-30 


it 


tt 


2 


ii 



34^ 



GENERAL HEMATOLOGY. 



these two accidents invariably raises the count ; for example, hem- 
atemesis is a symptom in fully 50 per cent, of patients suffering 
from ulcer of the stomach, yet in not more than 25 per cent, of 
all cases, both those with and those without this symptom, does 
the number of leucocytes exceed 10,000 to the cubic millimeter. 

The behavior of the leucocytes in the above-mentioned series 
of cases may be expressed thus : 

Above 10,000 in 5 cases. 

From 8,000-10,000 " 3 " 

" 6,000- 8,000 " 5 " 

" 4,000- 6,000 " 6 " 

" 2,000- 4,000 " i case. 

Average: 8,188 per cb. mm. 
Maximum : 16,000 " " " 
Minimum : 2,400 " " " 

In cases with leucocytosis the increase affects chiefly the poly- 
nuclear neutrophiles ; in those without leucocytosis minimum nor- 
mal or distinctly subnormal percentages of these cells are not un- 
common, and a total absence of eosinophiles is the general rule, 
these changes being counterbalanced by a proportionate increase 
in the small lymphocytes. 

Hematology gives no aid in distinguishing gas- 

Diagnosis. trie ulcer from gastralgia, duodenal ideer and 
simple gall-stone colic, in all of which leucocytosis 
is absent. The differences in the blood-pictures of gastric ulcer 
and cancer are referred to under the latter disease. (See " Malig- 
nant Disease.") 

XXIV. GLANDERS. 

Data are wanting regarding the condition of the hemoglobin and 
erythrocytes in human glanders, but it is known that leucocytosis is 
the rule. The bacillus mallei has been obtained by ante-mortem 
blood culturing, by Duval. 1 

XXV. GONORRHEA. 

The hemoglobin and erythrocytes are unaltered, but the acute 
febrile stage of specific urethritis is usually accompanied by a 
moderate polynuclear leucocytosis, which, in the event of any of 
the inflammatory complications of clap, may be much aggravated. 
Some authors formerly claimed that circulatory eosinophilia was 
a feature of this disease, but the more recent investigations of 
Vorbach 2 have shown that such a change, while occurring some- 

1 Archiv. de med. exper., 1896, vol. viii., p. 361. 
2 Inaug. Dissert., Wurzburg, 1895. 



GOUT. 



347 



times, is by no means constant ; he found in twenty cases that 
the percentage of eosinophiles ranged from as low as 0.05 to as 
high as 1 1.5. Bettman 1 believes that eosinophilia is especially 
frequent in posterior urethritis, an observation which thus far is 
unique. 

XXVI. GOUT. 

Garrod's 2 earlier teachings regarding the lowered alkalinity of 
the blood in acute gout have been contradicted, apparently with 
ample proof, by the later researches of Levy, 3 who failed to find 
a diminution in any of the 17 cases which he investigated by 
the most approved methods. Still more recently, Levy's con- 
clusions have been corroborated by the studies undertaken by 
Watson. 4 During an acute gouty seizure hyperinosis is an al- 
most invariable finding. 

It is questionable whether or not the amount of uric acid in the 
blood is greater during the acute stages than in the interval be- 
tween them, but it is nevertheless a fact that in many gouty 
persons uric acid crystals may be demonstrated in the blood by 
the ''thread-test" — a reaction by no means peculiar to this 
disease, as already pointed out. (See page 109.) 

The cellular elements show no characteristic alterations, and 
are normal except in long-standing cases in which an ordinary 
secondary anemia may develop in the course of time. During 
the acute attack a moderate increase in the number of leucocytes, 
affecting chiefly the polynuclear neutrophiles, may or may not be 
found. A relative increase in the eosinophiles is also sometimes 
encountered, both in cases with and without an increase in the 
leucocyte count. In one case of the writer's, the blood examined 
during the height of a severe paroxysm showed 100 per cent, of 
hemoglobin, 7,125,000 erythrocytes, and 14,000 leucocytes per 
cubic millimeter, the only peculiar differential change being the 
presence of myelocytes in the proportion of 0.4 per cent. The 
occurrence of these cells in gout has also been mentioned by Wat- 
son, 5 who found them in small numbers both during and between 
the acute seizures. (See page 107.) 

The same observer also states that he found (apparently in in- 
creased numbers), cells resembling blood plaques, as large as 4fi 
in diameter, often forming "very irregular torn-looking masses." 

1 Archiv. f. Dermat. u. Syph., 1899, vol. xxxix., p. 227. 

2 " Gout and Rheumatic Gout," London, 1876, p. 80. 
3 Zeitschr. f. klin. Med., 1898, vol. xxxvi., p. 336. 

4 British Med. Journ., 1900, vol. i., p. 10. 
5 Loc. cit. 



348 



GENERAL HEMATOLOGY. 



The worthlessness of Neusser's so-called perinuclear basophilic 
granules as a diagnostic sign of this condition has been alluded 
to in a previous section. (Page 176.) 

XXVII. HEMORRHAGIC DISEASES. 

From a hematological standpoint, scurvv, hem- 
General ophilia, and the various forms of purpura may 

Features, be conveniently considered together, since the 
blood changes in all of these conditions are sim- 
ilar, and in none are characteristic. 

The specific gravity of the blood varies with the degree of 
anemia present, but only in exceptional instances does it fall to 
an excessively low figure. Aiello 1 estimated it as low as 1043, 
in a case of purpura hemorrhagica in which the erythrocyte loss 
ranged between 50 and 60 per cent. The same investigator also 
detected methemoglobin in the blood, by spectroscopical examina- 
tion, in this form of purpura, which he attributes directly to auto- 
intoxication from the absorption of the products of decomposition 
occurring within the intestinal canal. Immerman 2 believed that 
in the late stages of hemophilia an increase in the total quantity 
of the blood, or a true plethora, exists, but this view is not enter- 
tained at the present time. 

Various bacteria, especially streptococci, staphylococci, and 
bacilli, have been found in the circulating blood by a number of 
observers, both in scurvy and in those forms of purpura due to 
infectious diseases. No special clinical significance, however, can 
be attached to these findings. The specific properties claimed by 
Letzerich 3 for his bacillus pur puree are not generally credited. 

The alkalinity of the blood, according to the studies of Cantani 4 
and others, is generally decreased in the hemorrhagic diatheses, 
although more recent investigators have disputed this fact, having 
found it higher than normal. Wright 5 has recently estimated 
the alkalinity in 7 cases of scurvy, a disease which he believes to 
be a condition of acid intoxication. He found in 3 of these cases 
that it corresponded to the figure N. 100, and to N. 200, N. 150, 
N. 1 10, and N. 80, respectively, in the remaining 4. As de- 
termined by this author's method, the alkalinity of normal blood 
is expressed by the formula N. 35, which means, in other words, 
that the degree of alkalinity is such that a mixture of one volume 

1 Rif. med., 1894, vol. ii., p. 103. 

2 Ziemssen's Handb. spez. Pathol, u. Ther. , 1879, vol. xiii., p. 2. 
3 Zeitschr. f. klin. Med., 1890, vol xviii., p. 517. 

4 "Spez. Pathol, u. Ther. der Stoffwechselkrankh.," Leipzig, 1884. 

5 Lancet, 1900, vol. ii., p. 1556. 



HEMORRHAGIC DISEASES. 



349 



of a thirty-five-fold diluted normal acid with an equal volume of 
blood serum is just sufficient to prevent the latter from reacting 
with sensitive blue litmus paper. 

The coagulation of the fresh blood drop is, as a rule, slow, and 
sometimes incomplete, these characteristics being observed with 
especial frequency in hemophilics. In such subjects Wright 1 
determined that clotting may fail to occur until after the lapse of 
over an hour after the withdrawal of the blood from the vessels, 
while in other instances the coagulation time ranged from 9 to 14 
minutes. Grawitz 2 has called attention to the fact that in cases 
with long-continued hemorrhage the clotting may be abnormally 
rapid, as is the case with normal blood after this accident. 

There are no characteristic changes affecting 
Hemoglobin the erythrocytes and hemoglobin, the blood- 
and picture being that of secondary anemia of variable 
Erythrocytes, intensity. In the majority of well-marked cases 
the erythrocytes do not suffer a loss of more than 
1,000,000 or 2,000,000 to the cubic millimeter, but the hemo- 
globin tends toward a proportionately greater decrease, making a 
low color index the rule. This is particularly noticeable in scurvy 
in which condition the hemoglobin loss is often twice as great 
as that of the cells ; in fact, some cases show simply oligochro- 
memia, with a normal number of erythrocytes. In 7 cases of 
infantile scurvy, examined by the writer, the hemoglobin percent- 
age ranged between 35 and 65, averaging 43.8, and the erythro- 
cyte count between 2,950,000 and 5, 100,000 per cubic millimeter, 
the average being 3,527,071. In three of these cases, with 
counts of 5,100,000, 4,900,000, and 4,814,000, respectively, the 
corresponding hemoglobin estimates were 52, 50, and 65 per 
cent. In severe cases, for example, of scurvy and purpura 
hemorrhagica, the count may fall to less than 1,000,000 and the 
hemoglobin to 20 per cent, or lower, these changes being accom- 
panied by all the qualitative alterations typical of a profound 
secondary anemia which sooner or later may prove fatal. Muir 3 
reports a case of purpura in which the hemoglobin was only 1 1 
per cent., and the erythrocytes 800,000 per cubic millimeter, and 
still more pronounced losses have been occasionally encountered 
by other observers. In mild cases the blood may be absolutely 
normal in every respect. Regeneration is rapid in cases which 
pursue a favorable course. It is well known that hemophilics 
appear to be less susceptible to the ill effects of hemorrhage than 

1 British Med. Journ., 1893, vol. i., p. 223. 

2 Loc. cit. 

3 British Med. Journ., 1900, vol. ii., p. 909. 



35o 



GENERAL HEMATOLOGY. 



other individuals, and that in this condition recovery from blood 
losses is usually rapid and uneventful, in spite of their number, 
extent, and chronicity. 

The leucocytes are usually increased both in 
Leucocytes, purpura and in scurvy, but in hemophilia a de- 
cided leucopenia may develop in spite of the ex- 
isting hemorrhages. The increase is typically polynuclear in 
most instances, although a relative excess of lymphocytes may 
occur. Stengel 1 found this change most striking in two cases of 
purpura hemorrhagica, and the writer has noticed an exaggeration 
of the lymphocytic tendency of children's blood in a number of 
cases of infantile scurvy. In 4 of the 7 cases of this condition, 
referred to in the preceding paragraph, the total percentage of 
lymphocytes was between 60 and 66 ; in 3 the percentage of 
polynuclear neutrophiles was from 27 to 35 ; the eosinophils aver- 
aged a low normal figure, and in all but a single case myelocytes 
were found, ranging in percentage from a minimum of 1 to a 
maximum of 6, and averaging 2.5 per cent. The actual number 
of leucocytes varied between 8,000 and 25,000, and averaged 
15,557 P er cu bic millimeter, all but a single case having a decided 
increase. Denys 2 has called attention to the presence of large 
numbers of leucocytes in the different stages of degeneration, 
both in scurvy and in the infectious form of purpura. 

In all the hemorrhagic conditions above men- 
Blood tioned, the blood plaques are usually much di- 
Plaques. minished in number, and sometimes absent. 

Especially is this the case in grave forms of 
scurvy and of purpura hemorrhagica. Hay em 3 believes that a 
marked diminution in the number of plaques plus a deficiency in 
clotting is a pathognomonic sign of the latter disease. 

XXVIII. HEPATIC CIRRHOSIS. 

In the early stages of atrophic cirrhosis, so long 
Hemoglobin as the patient's general health is maintained, the 
and blood remains practically normal, or shows, per- 

Erythrocytes. haps, only a moderate diminution in hemoglobin. 

But as the disease progresses, and the patient 
suffers from gastro-intestinal catarrh, hemorrhages, and circulatory 
embarrassment, an ordinary secondary anemia sooner or later 
becomes apparent, the intensity of this change depending upon 
the severity of the primary disease and its associated lesions. 

1 "Twentieth Century Practice of Medicine," N. Y., 1896, vol. vii., p. 485. 
2 Centralbl. f. allg. Pathol., 1893, vol. iv., p. 174. 
3 Compt. rend. l'Acad. sc., Paris, 1896, vol. cxxiii., p. 894. 



HEPATIC CIRRHOSIS. 



351 



Most advanced cases show a loss of from 2,000,000 to 3,000,000 
cells to the cubic millimeter, and a few an even greater oligo- 
cythemia. Hemorrhages, either repeated and small, or single 
and profuse, constitute the factor of a profound anemia in many 
instances. The average case of Laennec's cirrhosis loses more 
than 50 per cent, of hemoglobin and 30 per cent, of erythrocytes, 
while in the individual case the count may fall to between 1,500,- 
OOO and 2,000,000. The color index, as a rule, is moderately 
low; it averaged 0.70 for a series of 18 well-advanced cases ex- 
amined at the German Hospital, a synopsis of which shows these 
hemoglobin and erythrocyte values : 

Hemoglobin Number of Erythrocytes Number of 

Percentage. Cases. per cb. mm. Cases. 

From 70 to 80 2 From 4,000,000 to 5,000,000 4 

" 60 to 70 2 " 3,000,000 to 4,000,000 7 

" 50 to 60 5 " 2,000,000 to 3,000,000 6 

" 40 to 50 6 " 1,000,000 to 2,000,000 1 

" 30 to 40 3 

Average: 47.8 per cent. Average: 3,404,000 per cb. mm. 
Maximum: 80.0 " " Maximum: 4,850,000 " " " 
Minimum: 37.0 " " Minimum: 1,800,000 " " " 

The effects upon the blood of ascites are probably twofold and 
diametrically opposed. Primarily it is thought to cause more or 
less anemia by reason of the steady drain exerted upon the 
albuminoids of the blood, but this deterioration may be effectually 
masked by a polycythemia due either to peripheral stasis, or to 
inspissation of the blood caused by the rapid transudation of liquids 
from the vessels. This last factor is no doubt the cause of the 
polycythemia noted by von Limbeck 1 in cases after tapping. On 
the other hand, Grawitz 2 has demonstrated that a decrease in the 
hemoglobin and erythrocyte values may follow this operation, in 
cases in which the presence of a large ascitic exudate interferes 
with the circulation sufficiently to produce capillary stagnation and 
a consequent polycythemia, which the tapping dispels. 

Anemia is apparently more striking and more common in 
hypertrophic cirrhosis than in ordinary gin-liver. Judging from 
a rather limited experience in 6 cases, the writer finds a greater 
tendency toward corpuscular than hemoglobin loss, and conse- 
quently toward higher color indices. The index for these cases 
averaged 0.88, and in two it reached the figures 1.02 and 1.00, 
respectively. For the series the hemoglobin averaged 51.5 per 

1 Loc. cit. 
2 Loc. cit. 



352 



GENERAL HEMATOLOGY. 



cent., the minimum being 22, and the maximum 80 per cent. 
The average erythrocyte count was 2,908,333, and ranged from 
as low as 1,100,000 to as high as 4,290,000 per cubic millimeter. 

The usual degenerative and other qualitative changes accom- 
panying any severe secondary anemia may be found in the anemias 
of liver cirrhoses ; and, in addition, Hayem 1 has observed that in 
the hypertrophic variety there seems to be a marked tendency 
toward megalocytosis. 

In the great majority of atrophic cirrhoses the 

Leucocytes, number of leucocytes either remains normal or is 
distinctly decreased, while a few show a moderate 
degree of intermittent leucocytosis, to be regarded in all proba- 
bility, as a post-hemorrhagic change. It is questionable whether 
or not the jaundice present in some cases accounts for a leucocyte 
increase, although some authorities profess this belief. The leu- 
cocytes in the 18 cases tabulated above ranged thus : 

Leucocytes per cb. mm. 

From 10,000-15,000 in 4 cases. 

" 5,000-10,000 " 9 " 
Below 5,000 " 5 " 

Average: 7, 708 per cb. mm. 
Maximum: 12,000 " " " 
Minimum : 3,000 " " " 

In the 6 cases of hypertrophic cirrhosis the leucocytes averaged 
8,800 per cubic millimeter, the lowest count being 4,400, and the 
highest 14,800. Two of the estimates were above, and 4 below, 
10,000 cells to the cubic millimeter. Much higher counts than 
these, however, have been reported by others. While it must be 
admitted that leucocytosis is more frequent in this than in the 
atrophic variety, Hanot and Meunier's 2 claim that it is a constant 
symptom of hypertrophic cirrhosis is by no means justified. 

The leucocytoses of both these forms of the disease depend 
upon an absolute and relative increase in the polynuclear neutro- 
philes, at the expense of the other forms of cells. 

The blood examination fails to provide any 

Diagnosis. dependable signs by which cirrhosis is distin- 
guishable from other lesions of the liver, but 
a good idea of the inroads made by the disease upon the pa- 
tient's health may be gained by determining from time to time 
the grade of the anemia present. 

1( 'Du Sang," etc., Paris, 1889. 

2 Compt rend. Soc. biol., Paris, 1895, ios., vol. ii., p. 49. 



ICTERUS. 



353 



XXIX. HERPES ZOSTER. 

The blood changes in shingles have recently been studied by 
Samrazes and Mathias, 1 who found no appreciable diminution in 
the hemoglobin and erythrocytes, and no structural changes affect- 
ing the latter. Leucocytosis develops as early as the first day of 
the eruption, and progressively increases until about the third day, 
after which it gradually diminishes, until by the fifth day the 
count again reaches the normal figure. A secondary leucocytosis 
accompanies the period of desiccation and desquamation. A gain 
in the polynuclear neutrophiles and eosinophiles is accountable 
for the leucocytosis, which in some instances is associated with 
a few myelocytes. 

XXX. ICTERUS. 

Simple catarrhal jaundice, perse, produces little 
General or no effect upon the blood, except in the most 
Features, pronounced cases. The most conspicuous change 
consists in a greenish-yellow discoloration of the 
serum, due to the presence of bile. In patients suffering from 
obstructive jaundice (due, for instance, to gall-stones), a surgical 
operation may be complicated by dangerous, even fatal hemor- 
rhage, owing to the slow and imperfect coagulation of the blood. 
In the Jefferson Hospital, during the past three years, four pa- 
tients with jaundice due to malignant disease of the biliary appa- 
ratus have bled to death after operation. The quantity of fibrin is 
not increased. The specific gravity of the whole blood increases 
in relation to the intensity of the icterus, but the density of the 
serum is unaffected. In severe cases the alkalinity of the blood 
was found to be reduced, by de Rienzi. 2 

In mild cases the hemoglobin and erythrocytes 
Hemoglobin remain unaltered, but in severe jaundice a mod- 
and erate anemia is not uncommon, characterized by 
Erythrocytes, an absence of rouleaux formation, and by evi- 
dences of endoglobular degeneration marked out 
of all proportion to the grade of the cellular decrease. This 
association of a moderate oligocythemia with striking degenera- 
tive changes in the corpuscles appears to be peculiar to this affec- 
tion. In cases with symptoms of cholemia these degenerative 
changes are even more notable, but here the hemoglobin and 
erythrocyte losses also are more pronounced. Von Limbeck 3 
has observed that the volume of the individual erythrocyte is 

1 Rev. de sc. med., 1901, vol. xxi., p. 251. 
2 Virchow's Archiv., 1885, vol. cii. , p. 218. 
3 Loc. cit. 

23 



354 



GENERAL HEMATOLOGY. 



markedly increased. It is possible that in some instances the 
anemia is actually greater than the blood count indicates, for 
polycythemia, according to Becquerel and Rodier, 1 may develop 
by reason of inspissation of the blood from the action of bile. 

Most observers report that no leucocytosis 
Leucocytes, occurs in simple catarrhal jaundice, but Grawitz, 2 
on the contrary, states that he finds a constant 
increase in "uncomplicated cases of icterus," the count ranging 
in some instances as high as from 30,000 to 40,000 to the cubic 
millimeter. This author's report, however, does not represent 
the general consensus of opinion. Severe cases with cholemia 
may and usually do give rise to a well-developed leucocytosis. 

The association of icterus with leucocytosis, 
Diagnosis, except in obviously cholemic patients, suggests 
some purulent lesion, or malignant disease as the 
factor of jaundice, rather than uncomplicated duodeno-cholangitis. 

XXXI. INFLUENZA. 

General invasion of the circulation by the bacillus influenzce 
occurs very rarely, and the positive results from bacteriological 
examination of the blood claimed by Canon, 3 Klein, 4 and their 
contemporaries must be regarded as unsubstantiated, in the light of 
the large number of negative findings by Pfeiffer, 5 and by Kuhnau. 6 
Slawyk 7 has recently succeeded in cultivating this organism from 
the blood of a patient whose predominant symptoms suggested 
epidemic meningitis. Jehle, 8 although he admits the rare occur- 
rence of Pfeiffer' s bacillus in the blood of uncomplicated influenza, 
claims to have obtained many positive blood cultures of this 
organism in diphtheria, in pertussis, and in several of the ex- 
anthemata — measles, scarlet fever, and varicella. He attributes 
these findings to the fact that these diseases predispose to a 
secondary infection, especially to an influenzal bacteriemia. 

The hemoglobin and erythrocytes are normal in the great ma- 
jority of cases, a moderate diminution in these elements having 
been found only occasionally. 

Uncomplicated influenza is one of the few examples of an acute 
infection unaccompanied by a leucocytosis, although in some in- 

1 Archiv. de Physiol, norm, et path., 1874, 2 s., vol. i., p. 509. 
2 Loc. cit. 

3 Virchow's Archiv. , 1893, vol. cxxxi., p. 401. 
4 Baumgarten' s Jahresb., 1893, vol. ix., p. 206. 
5 Deut. med. Woch., 1893, vol. xix., p. 816. 
6 Loc. cit. 

7 Zeitschr. f. Hyg. u. Infectionskr. , 1899, vol. xxxii., p. 443. 
8 Zeitschr. f. Heilk., 1901, vol. xxii., p. 190. 



INSOLATION. 



355 



stances hyperinosis may be observed in the early stages of the 
attack. Rieder 1 states that a complicating catarrhal pneumonia 
causes either a moderate increase in the number of leucocytes, or 
none at all, but that in a post-influenzal croupous pneumonia the 
leucocytosis of this condition develops typically. 

It is unfortunate that an absence of leucocytosis is common to 
both enteric fever and influenza, for these two diseases are not in- 
frequently confused. The serum test, however, generally is con- 
clusive, if typhoid exists. Should a frank leucocytosis be pres- 
ent, croupous pneumonia, rather than influenza, is suggested. 

XXXII. INSOLATION. 

In the acute stages of thermic fever the hemoglobin and ery- 
throcyte values are unduly high, owing to the concentration of 
the blood from the excessive loss of body fluids by the lungs and 
the skin. Lambert, 2 for example, has observed a hemoglobin 
percentage of 125 in a sunstroke patient, while Vincent 3 states 
that the erythrocytes may number as high as 300,000 per cubic 
millimeter in excess of the normal average count. A more or less 
pronounced destruction of the eiythrocytes also occurs both dur- 
ing and after the acute stages of insolation, and this factor is re- 
sponsible for the anemia, sometimes decided, which subsequently 
develops. Owing to the coexistence of these two conflicting fac- 
tors, the real extent of the hematolysis cannot be determined until 
after the disappearance of the symptoms leading to blood concen- 
tration. This hematolysis is thought to depend upon the presence 
in the blood of some toxic element, since the hyperpyrexia itself 
is insufficient to cause disorganization of the cells. Schultze and 
Ranvier's experiments 4 have proved that such changes begin only 
when an animal is subjected to a temperature of from 54 0 to 56 0 
C. (or 1 29. 2° to 1 32. 8° F.). Levene and Van Gieson 5 have 
shown that the blood serum of sunstroke patients is a highly ac- 
tive blood-poison to animals, when injected intravenously. 

Some investigators have found an increased number of leuco- 
cytes, but others have been unable to detect any such change, so 
that leucocytosis must be regarded as an inconstant sign, depend- 
ing, perhaps, more upon the degree of blood condensation than 
upon any specific influence of the heat-stroke. Pigmented leuco- 
cytes have been observed in cases in which there existed marked 
signs of blood destruction. 

1 Miinch. med. Woch., 1892, vol. xxxix., p. 511. 

2 Loomis-Thompson : "A System of Practical Medicine," N. Y., 1898, vol. iii., 
p. 877. 

3 These d. Bordeaux, 1887-88, n. 8, p. 7. 

4 Cited by Vincent : loc. cit. 

5 Cited by Lambert : loc. cit. 



356 



GENERAL HEMATOLOGY. 



Wood 1 found that a decreased alkalinity or even an acidity of 
the blood was a conspicuous post-mortem change, but evidence 
is lacking to show that the reaction of the blood is altered during 
life. 

XXXIII. INTESTINAL HELMINTHIASIS. 

The presence in the intestinal canal of certain 
General parasites, notably the bothriocephalus latus and 
Features, the ankylostomum duodenale, is capable of pro- 
voking anemia of marked intensity in the indi- 
vidual harboring them. The ascaris lumbricoides also may be 
held responsible for anemia in some instances, but the blood 
changes attributable to this parasite are as a rule much less pro- 
found than those commonly met with in the two preceding forms 
of helminthiasis. Ostrovosky 2 has called attention to a case, 
unique of its kind, of fatal progressive anemia attributable to the 
presence in the intestines of the long threadworm, trichocephalus 
dispar. The cause of these anemias is generally attributed to the 
systemic effects on the host of certain soluble and absorbable 
toxic products eliminated by the parasites. That such poisons 
are produced, and that they undoubtedly can act in this dele- 
terious manner has been abundantly proved by many different 
investigators, among whom Hubner, 3 Reyner, 4 Schaumann, 5 As- 
kanazy, 6 and Lussana 7 may be named as authorities whom the 
student should consult for more detailed information on this topic. 
It is probable also that in cases of ankylostomiasis the anemia is 
kept up by the constant drain on the system caused by the direct 
abstraction of blood by the parasite. 

The blood changes due to bothriocephalus 
Hemoglobin latus infection are by far the most interesting, 
and from the clinician's standpoint, since the anemia 
Erythrocytes, caused by this worm may in some individuals 
exactly simulate primary pernicious anemia. The 
blood-pictures of the two conditions may be identical, both being 
characterized by marked and disproportionate oligocythemia, and 
consequently by a high color index, and by the presence of 
nucleated erythrocytes, the majority of which conform to the 
megaloblastic type. This so-called bothriocephalus anemia has 

1 "Thermic Fever or Sun-stroke" (Boylston Prize Essay), Phila., 1872. 
2 Vratch, Sept. 30, 1900. Abstr., N. Y. Med. Journ., 1900, vol. lxxii., p. 826. 
3 Deutsch. Archiv. f. klin. Med., 1870, vol. vii., p. 7. 

4 Ibid., 1886, vol. xxxix., p. 31. 

5 Bothriocephalus- Anemie," Berlin, 1894. 

6 Zeitschr. f. klin. Med., 1893, vol. xxiii., p. 80. Ibid., 1895, vol. xxvii., p. 492. 
7 Rivista clin., 1889, vol. iv., p. 750. 



INTESTINAL OBSTRUCTION. 



357 



been aptly described by Ehrlich 1 as "a pernicious anemia, with 
a known and removable cause." It is distinguishable from true 
pernicious anemia solely by the fact that after the expulsion of 
the worm by the administration of appropriate vermifuges the 
megaloblastic type of blood and the anemia rapidly disappear, and 
the patient makes an uneventful recovery. - 

The anemia of ankylostomiasis, while it may reach a very high 
grade of development, still does not counterfeit pernicious anemia. 
Griesinger's " Egyptian chlorosis," the brick-makers' anemia of the 
Germans, and the miners' anemia of the Italians, as well as many 
forms of tropical anemia, are all due to the effects of this nematode. 
The hemoglobin and eiythrocyte loss may individually be as great 
as is seen in Biermer's disease, but low color indices rule, since 
the former is more strikingly reduced than the latter. The erythro- 
cytes are commonly found in a state of marked deformity, both 
as to shape and size, polychromatophilia may be noted, and eryth- 
roblasts are often seen, but never, so far as our present knowledge 
indicates, is there a prevalence of megaloblasts, as there is in both 
bothriocephalus and in pernicious anemias. 

Leucocytosis does not accompany any of the 

Leucocytes, above-named forms of helminthiasis, except as 
the effect of some complication. As already 
pointed out (see page 200), a conspicuous feature of the blood is 
the frequent, but not constant, occurrence of both a relative and an 
absolute increase in the percentage of eosinophiles. The eosino- 
philia may be moderate or it may be enormous — in a case of an- 
kylostomiasis reported by Ashford, 2 40 per cent., or a total count 
of 7,200 eosinophiles to the cubic millimeter of blood; 72 per 
cent, in a case of the same disease and 34 per cent, in a patient 
harboring the tenia mediocanellata, these instances having been 
reported by Leichtenstern. 3 Even the oxyuris vermicularis, al- 
though it is not considered to be a factor in the production of 
anemia, may cause a well-marked increase in the percentage of 
eosinophiles, these cells sometimes constituting from 10 to 15 per 
cent, of all forms of leucocytes. 

XXXIV. INTESTINAL OBSTRUCTION. 

The hemoglobin and erythrocytes are unaffected, except in ob- 
struction due to malignant disease or associated with hemor- 
rhage, in which there may be a moderate secondary anemia. 

1 Loc. cit. 

2 N. Y. Med. Journ., 1900, vol. lxxi., p. 552. 
3 Cited by Ehrlich : loc. cit. 



358 



GENERAL HEMATOLOGY. 



Leucocytosis is a frequent, though not a constant, accompani- 
ment of all forms of ileus, even those with comparatively slight 
symptoms. The increase is most constant in obstruction de- 
pending upon malignant disease or complicated by gangrene and 
peritonitis, and in this class of cases it tends to reach the highest 
figures, except in the event of grave intoxication. Bloodgood 1 
regards the presence of a high leucocytosis (20,000 to 30,000) on 
the third or fourth day after the onset of symptoms as a favorable 
indication for operative interference, but he considers that low 
counts (below 10,000) under the same circumstances indicate 
extensive gangrene-peritonitis, or that the patient will be so de- 
pressed that reaction can not follow relief of the obstruction. 

XXXV. LEPROSY. 

The studies of Winiarski, 2 and of P. K. Brown, 3 show that in 
the early stages of this disease neither the hemoglobin nor the 
erythrocytes suffer any deterioration, but that in advanced leprosy, 
especially in cases with extensive ulcerative lesions, the anemia 
may be striking — quite as marked, in fact, as in a moderately 
severe case of true Biermer's anemia. In such instances there is 
a conspicuous oligocythemia in comparison to the oligochro- 
memia, and the counts may fall to below 2,000,000 to the cubic 
millimeter. A tendency toward megalocytosis, and high color 
indices has been observed, the index in some counts being as 
high as 1.7. Polycythemia, resulting from peripheral stagnation, 
may be a feature of some cases. The number of leucocytes is not 
increased, but a relative lymphocytosis is a commonly-observed 
differential change affecting these cells. 

Both Brown 3 and Streker 4 have succeeded in demonstrating 
the bacillus lepra in the circulating blood during life. These 
organisms, as a rule, were found to be enclosed in the leucocytes, 
and, more rarely, lay free in the plasma. On the other hand, 
Bibb 5 failed in 30 cases to find the bacillus by blood culturing, 
although he obtained positive results constantly with blood as- 
pirated from the leprous tubercles. 

The serum diagnosis of leprosy has not yet come into general 
clinical use, although positive clump reactions with cultures of 
the leprosy bacillus and the serum of lepers have been observed. 

Um. Med., 1901, vol. L, p. 306. 

2 St. Petersburg med. Woch., 1892, vol. ix., p. 365. 

3 Trans. California State Med. Soc., 1897, vol. xxvii., p. 168. 

4 Munch med. Woch., 1897, vol. xliv. , p. 1103. 

5 Am. Journ. of Med. Sc., 1894, vol. cviii., p. 539. 



MALARIAL FEVER. 



359 



XXXVI. MALARIAL FEVER. 

The specific cause of malarial fever is a form 
Parasitology, of blood parasite generally known as the Plas- 
modium malarial or the hemameba malaria, an 
organism classified among the Sporozoa, according to Metchni- 
kofif. 1 First accurately described in 1 880, by Laveran, 2 a medical 
officer of the French army, stationed in Algeria, our knowledge 
of the parasite and its relation to the malarial fevers has been 
furthered chiefly by the researches of Richard, 3 also a French 
army surgeon ; of Grassi and Filetti, 4 in Sicily ; of Mannaberg, 5 
in Austria; of Marchiafava and Celli, 6 Bastianelli and Bignami, 7 and 
Golgi, 8 of the Italian school; and of Councilman and Abbott, 9 Stern- 
berg, 10 Osier, 11 Dock, 12 and Thayer and Hewetson, 13 in America. 
In addition to these principal investigators, numerous workers in 
other parts of the world have materially advanced our knowledge 
of the subject. 14 

Developmental Cycle in Man. The malarial organism gains 
entrance to the erythrocyte of man, in which it pursues a definite 
cycle of development, at the expense of its corpuscular host. 
Existing in its earliest stages as a hyaline, ameboid body within 
the substance of the corpuscle, the parasite increases in size, and 
derives fine pigment granules from the hemoglobin of its host, 
which it ultimately destroys at the time its full maturity is attained. 
Full development of the parasite having been reached, it divides 
into a number of segments, which, by the rupture of the blood 
cell, are set free to enter fresh, uninvaded erythrocytes and there 

1 Centralbl. f. Bakt. u. Parasit. , 1887, vol. i., p. 624. 

2 " Nature parasitaire des accidents de 1'impaludisme," Paris, 1881. 

3 Gaz. med. d. Paris, 1882, vol. iv., p. 252. 

4 Centralbl. f. Bakt. u. Parasit., 1890, vol. viL, pp. 396 and 430. Ibid., 1891, vol. 
ix., pp. 403, 429, and 461. Ibid., vol. x. , p. 449. 

5 " The Malarial Parasites," New Sydenham Soc. Transl., London, 1894, vol. cl., 
p. 241. 

6 Forschr. d. Med., 1885, vol. hi., p. 787. Ibid., 1888, vol. vi., p. 450. Also 
Festchr. z. Virchow's 70. Geburtstag, 1891, vol. hi., p. 187. 

T Riforma med., 1890, vol. vi., pp. 860, 866, and 872. Also Lancet, 1898, vol. 
ii., p. 1461. 

8 Archiv. per le sc. med., 1886, vol. x., p. 109. 

9 Am. Journ. of Med. Sc., 1885, vol. lxxxix., p. 416. Also Med. News, 1887, 
vol. i., p. 59. 

10 Med. Record, 1886, vol. xxix.,pp. 489 and 517. 
"Phila. Med. Times, 1886, vol. xvii., p. 126. 

l2 Med. News, 1890, vol. lvii., p. 59. Ibid., 1891, vol. lviii., pp. 602 and 628. 
13 Johns Hopkins Hosp. Reports, 1895, vol. v., p. 3. 

14 For an exhaustive bibliography the reader should consult Thayer's admirable 
monograph, "Lectures on the Malarial Fevers," N. Y., 1897. An authoritative 
account of the malarial fevers in all their phases is given in Celli' s book, " Malaria 
According to the New Researches," English translation by J. J. Eyre. London and 
N. Y., 1900. 



360 



GENERAL HEMATOLOGY. 



to initiate a new developmental cycle of similar characteristics. 
Segmentation or sporulation of a group of parasites is accompa- 
nied by a paroxysm, which is in all probability due to the influ- 
ence of certain toxic material liberated at this time. 

But in order to complete its full life cycle, the malarial parasite 
must also pass through a developmental phase within the bodies 
of certain mosquitoes, for it has been shown that these insects not 
only act as the intermediate hosts of the parasite, but also carry 
the infection by means of their bite. These important discoveries 
were first made by Ross, 1 whose conclusions were shortly con- 
firmed by Grassi, Bignami, and Bastianelli, 2 and by others of 
the Italian school. 

Developmental Cycle in the Mosquito. While in the human 
body the malarial parasite pursues an asexual cycle, terminating 
in segmentation, in the body of mosquitoes of the genus Anopheles 
it follows out a true sexual cycle. In the blood of man certain 
of the parasites which do not undergo segmentation, constitute 
sexual forms of the organism, known as gametes, which, after 
having been imbibed by the mosquito while biting a malarious 
individual, develop into impregnated bodies by reason of the fe- 
cundation of the female sexual elements, or macrogametes, by the 
free flagella, or microgametes, which have become detached from 
the male sexual elements, or microgametocytes. The resultant 
fertilized bodies develop into motile pseudo-vermicules, which, 
having penetrated the muscular wall of the mosquito's stomach, 
lodge and become encysted in this situation and are now known 
as zygotes. From the latter are derived large numbers of delicate 
spindle-shaped cells, or sporoblasts, which, by the rupture of the 
zygote 's capsule, are set free, and, as sporozoids } make their way 
into the salivary gland of their host, whence they pass by way of 
the salivary duct into the proboscis of the insect, and conse- 
quently into the circulating blood of the individual stung by the 
infected mosquito. The sporozoids thus inoculated into the blood 
of man, penetrate his erythrocytes, in which, as the young hyaline 
forms of the malarial parasite, they pursue the typical develop- 
mental cycle to be described below. 

Thus, it has been definitely shown that mosquitoes of the genus 
Anopheles are capable of transmitting malarial infection from man 
to man, and it is now generally believed that this, the only proven 
method of malaria transmission, is probably the sole means by 

1 " Report on the Cultivation of Proteosoma (Labb6) in Gray Mosquitoes." Cal- 
cutta, 1898. 

2 Reale Accademia dei Lincei. Estratto dal, vol. vii., 2° sem., ser. 5a., fasc. n°. 
Seduta del 4 dicembre, 1898. Abst. in Progressive Med., Phila., 1899, vol. i., p. 
287. See also Bignami, Lancet, 1898, vol. ii., pp. 1461 and 1541. Grassi, II 
Policlinico, 1898, vol. v., p. 469. 



CHART III. 

SINGLE TERTIAN INFECTION. 
Paroxysm every third day. 

P. P. P. P. P. P. P. 

* ***** * 

i v v v v v "V 

Day. 1 2 3 4 5 6 7 S 9 10 11 12 13 



DOUBLE TERTIAN INFECTION. 
Daily paroxysm. 

P. P. P. P. P. P. P. P. P. P. P. P. 

** * **** ***** 

Day. 1 2 3 4 5 6 7 8 9 10 11 12 



SINGLE QUARTAN INFECTION. 
Paroxysm every fourth day. 
P. P. P. P. P. 

***** 

/ v v v \ 

Day. 1 2 3 4 5 6 7 8 9 10 11 12 13 



DOUBLE QUARTAN INFECTION. 
Paroxysm on two successive days with one day's intermission. 
P. P. P. P. P. P. P. P. 

** ** ** ** 



r 



I v— NF v V v V 



Day. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 



TRIPLE QUARTAN INFECTION. 
Daily paroxysm. 
P. P. P. P. P. P. P. P. P. P. 



/ — / / v — v 11 ^^/ — v^V ^ \r~V =" 

Day. 1 2 3 4 5 6 7 8 9 10 11 12 

CHART ILLUSTRATING THE DIFFERENT TYPES OF FEVER 
RESULTING FROM INFECTION WITH SINGLE AND WITH 
MULTIPLE GROUPS OF MALARIAL PARASITES. 

The duration of the parasites' cycle of development 
is expressed by colored lines, thus: 
Black: First group of parasites. 
Red: Second " " •« " 
Blue: Third " " " " 
P: Paroxysm. 



MALARIAL FEVER. 



which the disease is spread. The ordinary house-mosquito, of 
the genus Cidex, is not concerned in the transmission of malaria, 
since it has been proved that the parasites do not follow out a 
developmental cycle within the body of this insect. 

For a complete review of the "mosquito theory" of malaria, 
embracing the recent work of Ross, Manson, MacCallum, and 
the Italian school, the reader should consult Thayer's " Recent 
Advances in our Knowledge Concerning the ^Etiology of Malarial 
Fever," 1 Futcher's "A Critical Summary of Recent Literature 
Concerning the Mosquito as an Agent in the Transmission of 
Malaria," 2 and Howard's " Mosquitoes." 

Varieties of the Malarial Parasite. Three distinct varieties of 
the parasite are recognized, each of which has been found con- 
stantly associated with a specific type of malarial infection. These 
three varieties are : 

1. The parasite of tertian fever, associated with a regularly 
intermittent type of fever, with paroxysms eveiy third day. 

2. The parasite of quartan fever, associated with a regularly 
intermittent type of fever, with paroxysms every fourth day. 

3. The parasite of estivo-autumnal fever, associated with the 
more irregular types of fever. 

The parasites of tertian and of quartan fever exist in the blood 
of the infected individual in great groups consisting of immense 
numbers of organisms all of which are approximately at the same 
stage of development, and therefore undergo sporulation at about 
the same period. This fact serves to explain the regularity of 
the tertain and quartan paroxysms. On the other hand, in estivo- 
autumnal infections this regular grouping of the parasites is often 
wanting, and large numbers of this organism commonly exist in 
the blood in different stages of development. Sporulation thus 
taking place at irregular intervals, irregularity in the occurrence 
of the estivo-autumnal paroxysms is extremely common. 

As the development of these three types of the malarial para- 
site progresses, certain forms are evolved which possess more 
or less common characteristics, so that it is convenient to speak 
of these forms, which represent the maturing phases of the or- 
ganism, as follows : 

(a) The intracellular hyaline forms. 

( b ) The pigmented intracellular forms. 

(c) The pigmented extracellular forms. 

(d) The segmenting forms. 
( e ) The flagellate forms. 

1 Proc. Phila. Co. Med. Soc, 1900, vol. xxi., p. 211. 

2 Am. Journ. of Med. Sc., 1899, vol. cxviii., p. 318. 



362 



GENERAL HEMATOLOGY. 



Furthermore, in parasites of the estivo-autumnal type addi- 
tional forms, those of the crescent group, are met with, these 
varieties being peculiar to this type of infection, and never occur- 
ring in tertian and quartan fevers. 

Tertian infections constitute the prevailing type of malarial 
fever in almost all countries in which the disease exists. Quartan 
fevers are relatively uncommon, except in certain limited districts, 
parts of Sicily, for example, in which a large proportion of the 
cases conform to this type. Estivo-autumnal fevers are especially 
common in the tropics, but this type of the disease is by no means 
incompatible with temperate regions. In Philadelphia and its en- 
virons tertian infections are about five times as common as those 
of the estivo-autumnal type, while quartan malaria is practically 
unknown. The writer has seen but a single instance of quartan 
infection in this vicinity, and this case was without doubt imported. 

The Parasite of Tertian Fever. (Plate VI.) The tertian parasite 
attains its full development in about forty-eight hours, segmenta- 
tion of a single group of organisms at this interval producing the 
characteristic paroxysms every third day. Infection with two dis- 
tinct groups of parasites, each maturing on successive days, gives 
rise to a quotidian type of fever, characterized by the occurrence of 
daily paroxysms. (See Chart III., p. 361.) Infection with more 
than two groups is extremely rare, and produces an atypical and 
irregular type of fever. 

Anticipation of the paroxysm, which is especially frequent in 
tertian fever, may be explained by a precocity displayed by a 
group of parasites, by virtue of which their development is so 
rapid that the stage of sporulation is reached before the expira- 
tion of forty-eight hours. On the contrary, should the develop- 
ment of a group happen to be slower, requiring more than forty- 
eight hours for its full maturity and sporulation, then the paroxysm 
is retarded. 

If a specimen of fresh, unstained blood from a case of tertian 
fever is examined during the period immediately or shortly fol- 
lowing the malarial paroxysm, it will be observed that many of 
the erythrocytes contain small, pale, transparent, foreign bodies, 
dim of outline, more or less markedly ameboid in character, and 
of a peculiar dirty, grayish-pearl tint. These bodies, known as 
the intracellular hyaline forms, represent the youngest forms 
of this organism, being derived from the sporulation of the im- 
mediately preceding group of parasites. They may occasionally 
be found in the peripheral blood toward the latter part of the 
paroxysm, and for a short time after the occurrence of this 
phenomenon. 



PLATE VI. 



V^Jr ^'Z^jr yti^m' ' 

1 2 3 4 5 6 



10 11 



14 

12 13 



The Tertian Parasite. 



1. Normal erythrocyte. 

2, 3, 4, 5. Intracellular hyaline forms. 

6, 7. Young pigmented intracellular forms. In 6 two distinct parasites inhabit the ery- 
throcyte, the larger one being actively ameboid, as evidenced by the long tentacular 
process trailing from the main body of the organism. This ameboid tendency is 
still better illustrated in 7, by the ribbon-like design formed by the parasite. Note 
the delicacy of the pigment granules, and their tendency toward peripheral arrange- 
ment in 6, 7, and 8. 

8. Later developmental stage of 7. In 7, 8, and 9 enlargement and pallor of the infected 

erythrocyte become conspicuous. 

9. Mature intracellular pigmented parasite. 

10. 11, 12. Segmenting forms. In 10 is shown the early stage of sporulation — the develop- 

ment of radial striations and peripheral indentations coincidentally with the swarm- 
ing of the pigment toward the center of the parasite. The completion of this process 
is illustrated bv 11 and 12. 

13. Large swollen extracellular form. Note the coarse fused blocks of pigment. (Com- 

pare size with that of normal erythrocyte, 1.) 

14. Flagellate form. 

IS- Shrunken and fragmenting extracellular forms. 
16. Vacuolation of an extracellular form. 

Note. — The original water-color drawings were made from fresh blood specimens, a 
Leitz T l 2 -inch oil-immersion objective and 4 ocular, with a Zeiss camera-lucida, being used. 






(E. F. Faber, /,?<:.) 



MALARIAL FEVER. 



363 



The ameboid movements of these hyaline bodies form one of 
their most striking features, and in consequence of this trait their 
shape is constantly altered. At one moment the parasite ap- 
pears as a flattened spherical or oval disc, measuring 2 or 3 p. in 
diameter; the next instant it may change to the shape of a jack- 
stone, or become a stellate design, or take the form of an anvil. 
The succession of figures which the organism may resemble is 
limitless. As the parasite increases in size, long pseudopodia, 
like the delicate tendrils of a vine, are alternately thrown out 
and retracted, reaching here and there through the corpuscular 
substance with uncertain but sudden motility. In the active par- 
asite these pseudopodia appear as long, delicate, gracefully 
curved branchings of the protoplasm, usually terminating in a 
spherical knob-like extremity, and measuring 4 or 5 //in 
length, in many instances. Occasionally the parasite seems to 
have formed a perfect ring, either because of the thinning out of 
its central portion, or, rarely, by reason of the fusion of two short 
pseudopodia between which a small portion of the corpuscle 
becomes imprisoned. The outline and color of the hyaline body 
are quite characteristic, at least to the eye of the practised ob- 
server. Usually described as quite colorless, the parasite rather 
possesses a distinctive pearly tint, overlaid in patches by layers 
of corpuscular substance of varying depth, so that in certain lights 
the yellowish-green color of the erythrocyte predominates, and ob- 
scures the true color of the organism to some extent. Usually but a 
single hyaline body, situated somewhat eccentrically, is found in 
the corpuscle ; less commonly, two or more are harbored. 

The next stage in the development of the organism, the col- 
lection of pigment granules derived from hemoglobin of the 
erythrocyte, is reached toward the latter part of the first twenty- 
four hours following the paroxysm. By this time the size of the 
parasite has increased to about half that of its corpuscular host, 
and it is now known as an intracellular pigmented form. 

The pigment appears as a collection of exceedingly fine, yel- 
lowish-brown granules which are usually most densely distributed 
near the peripheral rather than the central portion of the parasite. 
In the large spherical forms of the latter, most of the pigment is 
arranged in a series of irregular clumps, loosely strung together 
by delicate, wavy connecting lines consisting of individual gran- 
ules ; or the rim of the parasite may be paralleled for the greater 
part of its extent by a pigment design not unlike a wreath or a 
hoop. The individual granules are observed to be in active, in- 
cessant motion, their violent oscillations hither and thither form- 
ing a picture that at once arrests the attention of the observer. 



364 



GENERAL HEMATOLOGY. 



In many of the ameboid figures, a polar distribution of the pig- 
ment is noticeable, the greater part of the granules being situated, 
in fine clumps, in the knob-like extremities of the several pseudo- 
podia ; and even in these situations the typical tendency of the 
pigment to arrange itself eccentrically, is striking. 

As the parasite matures, it becomes of still larger size, more 
and more pigmented, and less and less ameboid, the latter char- 
acteristic becoming quite or almost entirely lost by the time it 
attains its full growth. The pigment, fine, of yellowish-brown 
color, and eccentrically distributed in the earlier forms, is at this 
period of the organism's growth much coarser, darker in color, 
and more scattered throughout the protoplasm. Some of the 
granules are fused into minute, dark-colored spikes and rods, in 
contrast to the discrete, dot-like granules of the younger parasites. 

Coincidentally with these changes, striking alterations are ap- 
parent in the invaded erythrocytes. These cells become pro- 
gressively paler and more swollen as the development of the para- 
site goes on, until at the time of the latter' s full maturity (attained 
after a growth of about forty hours' duration) the corpuscles 
have become almost entirely decolorized, and appear now as hya- 
line or pale yellowish rims encircling the parasite, the size of which 
is now approximately equal to that of a normal erythrocyte. 

Just before and during the next paroxysm, or from about forty 
to forty-eight hours after the preceding chill, the parasite attains 
its full maturity, and the stage of sporulation occurs. Coinci- 
dentally with this, segmenting forms of the parasite begin to appear 
in the blood. In tertian infections segmentation occurs to a 
greater extent in the deep than in the peripheral circulation, but 
if finger blood is obtained two or three hours before the chill, a 
few " segmenters " will almost always be found, if the search 
for them is careful and thorough. In cases in which the number 
of parasites has been scanty during the preceding days of the at- 
tack, it may be impossible to detect these forms, in spite of careful, 
skilled observation. 

Segmentation is heralded by a tendency of the pigment gran- 
ules to collect in or near the center of the parasite, in one large 
or in several smaller compact clumps, or fused masses. This 
having taken place, a number of minute, somewhat refractive 
points may be seen with more or less distinctness, the majority 
of these spots being confined to the peripheral portion of the organ- 
ism, which by this time has lost a great deal of its earlier clear, 
hyaline appearance, and has become dully opaque, and somewhat 
granular. Following the development of these refractive points, 
indistinct parallel linear shadings, usually fifteen or twenty in 



MALARIAL FEVER. 



365 



number, extending from the periphery of the parasite toward the 
central collection of pigment, may be discerned ; and coincidentally 
with this change the rim of the parasite becomes wrinkled, then 
distinctly corrugated, each corrugation capping a pair of these 
radiating shadings. The latter finally become the dividing lines 
of fifteen or twenty spores or segments, of somewhat round or 
ovoid shape, radiating in an irregular figure toward the central 
pigment mass. By careful focusing, each segment is found to 
contain a central refractive spot, the whole collection being sur- 
rounded and held together by the shell of the erythrocyte, now 
so decolorized that it is scarcely visible. 

Finally, when segmentation is completed, the spores, for as such 
these segmenting bodies must now be considered, are freed from 
the body of the corpuscle which has served until this time as 
their limiting capsule. The latter having apparently ruptured, 
the spores escape, either by gradually emerging several at a time, 
or by the simultaneous and extremely abrupt exit of their whole 
number. The spores, which now lie free in the blood plasma, 
surround the remains of the central pigment mass in an irreg- 
ular group, which has been likened in appearance to a bunch of 
grapes. Sooner or later they wander off through the plasma and 
disappear from view, the inference being that they invade fresh 
erythrocytes and thus initiate a new cycle of development of 
another forty-eight hours' duration. Although visual proof of 
this invasion is lacking, the fact that hyaline bodies, biologically 
similar to these free spores, are found in the erythrocytes at or 
shortly after the time of segmentation, must be regarded as suf- 
ficiently strong evidence of the truth of this inference. Most of 
the liberated pigment is carried off through the blood, to be de- 
posited in various organs, while some of it is taken up by phago- 
cytes. 

The preceding remarks refer to the typical cycle of the par- 
asite's development, from the smallest hyaline intracellular body 
to the full-grown pigmented segmenting variety, from which the 
former is derived. But all the parasites of one group do not 
pursue this routine, some escaping prematurely from the eryth- 
rocyte at an early period of their life history, others continuing 
to develop further,' and losing their corpuscular capsule just prior 
to the time segmentation begins in the other parasites of the 
same group. In consequence of these changes, another distinct 
class of tertian parasites, the extracellular pigmented forms \ is pro- 
duced, and it is the varieties of this class that Ave now have to 
consider. 

In the first instance, the young, slightly pigmented parasite 



366 



GENERAL HEMATOLOGY. 



escapes from its corpuscular host through an apparent breach in 
the surface of the latter. The immediate effect of its contact 
with the blood plasma is to convert it into a deformed, dwarfed 
body of protoplasm, which sooner or later becomes wholly de- 
void of ameboid motion. It is often fragmented, and divided into 
two or more small rounded masses, each containing an amount 
of pigment seemingly disproportionate to its size, compared to 
the quantity found in the intracellular forms. Sometimes two of 
these pigmented spheres are joined to one another by a filmy con- 
necting thread of protoplasm, from 3 to 5 fx in length, forming a 
design which may be compared to a miniature chain-shot. After 
the lapse of a short length of time, the outlines of these bastard 
forms of the parasite become almost indistinguishable. The eryth- 
rocytes from which they have escaped become completely decolor- 
ized and invisible shortly after this accident has occurred. 

In the second instance, in which the parasite loses its corpus- 
cular envelope just before the time of segmentation, the resulting 
spherical extracellular body is usually of large size, often 9 to 
12 fi in its greatest diameter, or, in the smaller forms, about the 
size of the normal red cell. It is filled with actively moving pig- 
ment granules, arranged either peripherally, or scattered through- 
out its body, and standing out in bold relief against the back- 
ground formed by the pale surface of the parasite. The granules 
in this form of the organism are usually quite dark in color, some 
of them being welded and fused into minute spiculate figures, 
while others remain free and distinct. 

These extracellular pigmented bodies are of especial interest, 
for the reason that from them develop those most striking varie- 
ties of the malarial parasite, the flagellate forms. The earliest 
evidence of the process of flagellation is seen in the strikingly 
increased activity of the pigment, the oscillations of the granules 
growing more and more violent with the approach of the phe- 
nomenon. Then, one or more long, almost transparent tentacular 
processes are observed suddenly to burst from the periphery of 
the parasite, their violent and incessant whipping about in the 
plasma causing more or less disturbance of the blood corpuscles 
in their vicinity. The pigment granules, meanwhile, have 
swarmed together into a loose mass at or near the center of the 
main body. The length of the flagella varies from 4 to 5 to 20 
fx or longer, their average breadth being somewhat less than .5 
fx. They frequently possess one or more bulbous swellings, 
usually at their distal extremity, occasionally at their proximal 
end, and also at other points along their course intermediate to 
these situations. They may or may not contain a few fine and 



PLATE VII. 



2 3 4 5 6 



7 8 9 10 11 



12 t- ^l V* 

•* " /' 13 V# 14 



The Quartan Parasite. 



1. Normal erythrocyte. 

2. Intracellular hyaline form. 

3. Young- pigmented intracellular form. Note the coarseness, dark color, and scantiness 

of the pigment granules. 

4. 5, 6, 7. Later developmental stages of 3. Note the peripheral distribution of the pigment 

in all the parasites from 3 to 8. (Compare size and color of the erythrocytes in 5, 6, 
and 7 with 7, 8, and 9, Plate VI.) 

8. Mature intracellular form. Note that the stroma of the erythrocyte is no longer 

demonstrable. 

9, 10, 11. Segmenting forms. In 9 are shown the characteristic radiating lines of pigment. 

(Compare with 10, 11, and 12, Plate VI, and with 10, ir, and 12, Plate VIII.) 

12. Large swollen extracellular form. (Compare with 13, Plate VI.) 

13. Flagellate form. (Compare with 14, Plate VI.) 

14. Vacuolation of an extracellular form. 



(E. F. Faber, /<?c.) 



MALARIAL FEVER. 



active dotlets of pigment situated in the swollen extremity, or 
sprinkled as fine stipplings along their course. 

The ultimate disposition of the flagella occurs in one of two 
ways : they either become detached from the large spherical 
parasite, and, as free flagella, wander off through the plasma, 
propelled by their own ameboid movements, which finally cease, 
after which they soon disappear from view ; or, remaining attached 
to the large body, they are observed to disappear by apparently 
reentering the large parasite and becoming reincorporated with 
its protoplasm. Flagellate forms do not occur in the circulating 
blood, and are not found in the fresh specimen until some little 
time, usually from ten to twenty minutes, has elapsed after the 
withdrawal of the blood from the body. They are most easily 
found in blood which has been taken from the patient just before 
the onset of a paroxysm. The nature and functions of these 
flagellate bodies were first clearly determined by MacCallum, 1 
who proved that the flagella are true male sexual organs, actively 
concerned in the process of fertilization, to which reference has 
already been made. (See page 360.) 

Some of the extracellular bodies, failing to develop flagella, 
undergo vacuolization, often become exceedingly misshapen, and 
sometimes fragmented, these changes being regarded as degenera- 
tive in character. A parasite thus affected loses its regularly 
spherical outline, and may so alter in appearance that it resembles 
a gourd, or a partly inflated balloon. Constrictions at one or 
more points may appear, and in the little knobs thus cut off from 
the main body of the organism, a few actively motile pigment 
granules are usually imprisoned. Small portions of the original 
body, containing active pigment, may become extruded and float 
off through the plasma, but sooner or later the pigment in these 
fragmented bits loses its motility and the bodies themselves 
become deformed and so indistinct of outline that they are lost 
to view. These degenerative forms closely resemble those de- 
rived from prematurely-escaped intracellular parasites, except 
that the latter, as a rule, contain finer and less abundant pigment. 

2. The Parasite of Quartan Fever. (Plate VII.) The quartan 
parasite completes its cycle of development in about seventy-two 
hours, thus producing a paroxysm every fourth day. Infection 
with two separate groups of parasites is marked clinically by a 
paroxysm occurring on each of two successive days, separated by 
one day of intermission. Infection with three groups of parasites 
produces daily paroxysms, the resulting quotidian type of fever 

1 Journ. of Exper. Med., 1898, vol. iii., p. 117. Also, Johns Hopkins Hosp. 
Bull., 1897, vol. viii., p. 236. 



3 68 



GENERAL HEMATOLOGY. 



being similar to that due to double tertian infections. (See Chart 
III., page 361.) 

Ordinarily, the quartan parasite's cycle of development is ex- 
tremely regular, the period required for its maturation seldom 
deviating from seventy-two hours. It is owing to this that antici- 
pation and retardation of the paroxysm, so common in tertian in- 
fections, are rare in the quartan types of fever. 

The young hyaline forms of the quartan parasite closely re- 
semble those of the tertian organism ; they have the same hyaline 
appearance, the same indistinct outline, and the same sort of 
ameboid movement. While the quartan hyaline body is 
usually described as being of smaller size and less ameboid than 
the similar tertian form, these differences are not well enough 
marked to be of practical application. At this stage of its life 
history, the organism of quartan fever possesses no distinctive 
characteristics by which it may be differentiated from the tertian 
variety of a similar period of growth. It is not until it has matured 
to the stage of pigmentation that it is possible to discern points 
of distinction by which its identity may be fixed — characteristics 
which become more and more striking as development of the 
parasite progresses, and which relate to its color, outline, pigment, 
and ameboid powers, as well as to changes affecting its corpus- 
cular host. 

The outline of the pigmented intracellular form is much more 
distinct than that of the tertian, its margins contrasting rather 
than blending with the color of the surrounding erythrocyte. 
The appearance of its protoplasm is also quite different, being ap- 
parently denser in consistence, more highly refractive, and unob- 
scured by the color of the overlying corpuscular substance. 
Thayer 1 has happily compared this difference in refraction and 
distinctness of outline between the tertian and quartan parasites to 
the difference between a pale hyaline and a waxy cast in the 
urine — a comparison which precisely expresses these points of 
dissimilarity. 

The pigment granules, fine, yellowish-brown, and violently 
motile in the tertian variety, are coarse, dark brown or almost 
black, and sluggishly motile, in the quartan form. They early 
tend to form little spicula and rods, intensely dark in color, and 
compactly arranged, being frequently grouped together in masses 
like coffee grounds, in one corner of the parasite. 

By the time the organism reaches about one-half or two -thirds 
the size of the corpuscle in which it is contained, it may be ob- 
served that its ameboid movements, which in the earlier stages of 

Lectures on the Malarial Fevers." N. Y., 1897. 



MALARIAL FEVER. 



369 



its existence were quite active, have now become sluggish, slow, 
and inconspicuous. In consequence of this limited motility, the 
long tentacular shoots of protoplasm, so familiar in the tertian 
form, are not seen, the quartan parasite inclining to form resting 
figures, oval, or round, or somewhat elongated in outline. The 
pigment does not oscillate violently, but moves about a more 
limited area, with a sort of deliberate, tugging motion. It is dis- 
tributed about the periphery, which it parallels for only a short 
distance, not tending to produce the wreathed designs commonly 
observed in the tertian organism at a corresponding stage of its 
maturity. 

As the parasite matures, its ameboid powers progressively di- 
minish, until at a period usually after the forty-eighth hour fol- 
lowing the last paroxysm little or no motility of either proto- 
plasm or of pigment is distinguishable. 

The corpuscular host meanwhile undergoes striking changes 
in comparison to the erythrocyte invaded by the tertian organ- 
ism. Instead of becoming swollen and pale, as in the latter in- 
stance, on the contrary, it becomes shrunken, darker colored, and 
sometimes "brassy." It is not until segmentation is imminent, 
or from about ten to twelve hours before the impending paroxysm, 
that decolorization of the blood corpuscle becomes marked. At 
this period of its cycle, the parasite measures about 7 or 8 fi in 
diameter, and is apparently, although not actually, unconfined by 
a corpuscular envelope, the latter now having become rapidly 
decolorized and finally quite invisible. 

As segmentation approaches, the pigment collects in the center 
of the organism, which now becomes more opaque and de- 
velops a number of refractive dots, which later become the nuclei 
of from six to twelve segments, developed by a progressive deep- 
ening of parallel radial striations extending from the periphery to 
the center of the parasite. The segmenting quartan parasite forms 
a perfect rosette, the individual spores being of equal size and of 
the same shape, and the collected mass of spores being very 
symmetrically arranged. Coincidentally with segmentation, a new 
group of young hyaline parasites may be found in the hitherto- 
uninvaded red corpuscles, indicating the beginning of another 
cycle of the parasite's development, which, if unchecked, persists 
for seventy- two hours. 

Thayer 1 mentions a star-like arrangement of the pigment in 
the early stages of the segmenting quartan organism, as if the 
granules had flowed inward in distinct streams during the process 
of collection, and this picture he is inclined to consider character- 

1 Loc. cit. 

24 



370 



GENERAL HEMATOLOGY. 



istic. The author is able to verify Thayer's observation, having, 
in a limited experience with the quartan parasite, never failed to 
find this peculiarity, its absence having been equally conspicuous 
in malarial organisms of other types. 

The quartan parasite completes every phase of its development 
in the circulating blood, so that all stages of its cycle, from the 
earliest hyaline forms to the segmenting and flagellate bodies, may 
be studied in the peripheral blood. 

Extracellular pigmented forms, which have parted with all traces 
of their corpuscular capsule without having undergone segmenta- 
tion, may also be observed. They average less in diameter than 
similar forms of the tertian parasite, the largest of the quartan 
forms being about equal in size to the smallest of the tertian. 
Their pigment granules are coarse, very dark colored, and situ- 
ated chiefly toward the periphery, with a greater or less drifting 
inward of individual pigment clumps apparently composed of two 
or three agglutinated coarse granules. 

Flagellate bodies, smaller in size and containing coarser granules 
than corresponding tertian forms, develop from these swollen ex- 
tracellular parasites, the onset of flagellation being portended by 
increased activity and centralization of the pigment in direct antici- 
pation of the appearance of the flagellate appendages. 

Degenerate forms of the parasite, vacuolized, fragmented, and 
otherwise deformed, may be also observed, but with less frequency 
than in tertian fever, probably for the reason that extracellular 
forms of the quartan parasite are not so common as those of the 
tertian organism. The writer has especially noticed the infre- 
quency of fragmentation and other deformity of those organisms 
which have prematurely emerged from their corpuscular host, 
atypical varieties of the more mature free bodies being compara- 
tively much commoner. 

3. The Parasite of Estivo-autumnal Fever. (Plate VIII.) The 
developmental cycle of the estivo-autumnal parasite exhibits 
marked irregularity as to the length of time required for its com- 
pletion, in contrast to the routine forty-eight- and seventy-two- 
hour cycles in which the tertian and quartan organisms round out 
their life histories. In some instances the cycle of the estivo- 
autumnal parasite is of only twenty-four hours' duration, while in 
others it is quite forty-eight hours, or perhaps longer. This in- 
constancy of type is thought to depend upon some peculiarity of 
the organism, by virtue of which the time required for its matu- 
ration may widely fluctuate under different conditions of quite 
obscure character. It is not generally believed that the com- 
mon types of fever, quotidian and tertian, respectively, depend 



PLATE VIII. 



11 



15 



16 



17 



19 



ft 
20 



22 



0 



25 



26 



The Estivo-Autumnal Parasite. 



1. Normal erythrocyte. 

2, 3. Young hyaline ring-forms. 

4, 5, 6. Intracellular hyaline forms. In 4 the parasite appears as an irregularly shaped disc 
with a thinned-out central area. In s and 6 its ameboid properties are obvious. 

7. Young pigmented intracellular form. Note the extreme delicacy and small number of 

the pigment granules. (Compare with 6, Plate VI, and with 3, Plate VII.) 

8, 9. Later developmental stages of 7. 
10, 11, 12. Segmenting forms. 

13, 14. Crescentic forms at early stages of their development. 

15, 16, 17, 18, 19. Crescentic forms. In 15 and 19 a distinct "bib" of the erythrocyte is visible. 
Vacuolation of a crescent is shown in 18, and polar arrangement of the pigment in 17. 

20. Oval form. 

21, 22. Spherical forms. 

23. Flagellate form. 

24. Vacuolatio7i and deformity of a spherical form. 

25. Vacuolated leucocyte apparently enclosing a dwarfed and shrunken crescent. 

26. Remains of a shrunken spherical form. 



(E. F. Faber, /><:.) 



MALARIAL FEVER. 



371 



upon infection with two special forms of the estivo-autumnal 
parasite, although this view is held by some authors, notably by 
Mannaberg, 1 ancTby Marchiafava and Bignami, 2 all of whom rec- 
ognize both a quotidian and a tertian variety of the organism ; 
the former, furthermore, describes a pigmented and an unpig- 
mented form of the quotidian variety. 

Certain phases of the young hyaline forms of the estivo- 
autumnal parasite bear a striking resemblance to similar forms of 
the tertian and quartan organisms, but other phases are, on the 
contrary, just as strikingly dissimilar. As a rule, the estivo- 
autumnal hyaline body is much smaller than those just described, 
its margins are more sharply defined from the corpuscular sub- 
stance, and it appears to possess a greater degree of refraction. 
But these are minor points of difference, the chief distinction 
relating to the peculiar morphological changes to be observed in 
these immature parasites. At one moment they may appear as 
pale, rounded or somewhat oval bodies, situated rather toward 
the periphery of the corpuscle than in its center, and usually 
possessing active ameboid movements which produce various 
stellate and forked designs. On closer observation, certain other 
striking changes may be noted in these round forms. These 
changes consist in the formation of the so-called ring-shaped 
bodies, due to the development of a more or less marked bicon- 
cavity of the hitherto flattened hyaline body, either in its center, 
in event of which the parasite appears as a true ring or hoop, or 
more toward its periphery, in which instance a figure resembling 
a signet-ring is produced. These figures remain visible for a 
variable length of time, the parasite meanwhile being apparently 
in a resting stage, but sooner or later its ameboid powers are 
reasserted, with the result that the biconcavity abruptly disappears, 
converting the ring-shaped body into- its original form of an 
ameboid, flattened disc. This successive alteration in shape, 
from disc to ring to disc, regardless of the other changes in shape, 
is highly characteristic of the estivo-autumnal organism, and is 
fully as valuable a diagnostic sign as the more striking pictures of 
the maturer forms, to be considered later. The size of the ring- 
shaped parasites varies from less than 2 p. in diameter, to about 
3 //. They are rarely situated in the exact center of the cor- 
puscles, more commonly being found lying midway between the 
center and the periphery, or, indeed, quite upon the latter. 

As the parasite matures, pigment, in the form of a few ex- 
ceedingly fine, scattered granules, begins to appear. The gran- 

1 Nothnagel's Spec. Path. u. Ther., Wien., 1899, vol. ii., p. 68. 
2 New Sydenham Soc. Transl., London, 1894, vol. cl., p. I. 



372 



GENERAL HEMATOLOGY. 



ules are very few in number, dark brown in color, and are usually 
situated toward the edge of the organism. They may or may 
not be motile, usually not. Strikingly pigmented forms of the 
estivo-autumnal parasite are never observed, in marked contrast 
to the abundant fine pigment of the tertian forms, and to the coarse 
granules typical of the quartan varieties. 

The development of the parasite up to this stage can be studied 
in the peripheral blood, but the older forms of the pigmented 
bodies, and their final division into spores, by segmentation, occur 
almost exclusively in the deeper circulation, and must be fol- 
lowed out in blood obtained from one of the internal organs, such 
as the spleen, which may be aspirated for this purpose, although 
the procedure is not without risk to the patient. In the finger 
blood the writer has never seen presegmenting forms more ma- 
ture than those represented by the young slightly pigmented 
parasite, and has never had the good fortune to meet with seg- 
menting bodies except in specimens derived from the spleen. 
The general rule is to find in the peripheral blood nothing 
more than hyaline ameboid and ring-shaped bodies, or, perhaps, 
a few organisms containing two or three minute granules of 
pigment. 

If now a drop of blood, aspirated from the spleen, is examined, 
the remainder of the parasite's cycle may be traced with fair ac- 
curacy. As it approaches the stage of segmentation, the para- 
site develops into a spherical body, measuring from about 2 to 
6 fx in diameter, and having a distinct outline which limits 
it from the surrounding substance of the red blood corpuscle, 
which it only partly fills. The pigment granules, which by 
this time are moderately but never strikingly increased in num- 
ber, show a marked tendency to become concentrated near the 
center of the organism. They here exist as a tightly clumped, 
compact mass, in which the identity of the individual granules 
is completely lost, as they have now become fused into a single 
distinct, dark-colored, round or somewhat elongated mass. 

As segmentation commences, the parasite becomes opaque, 
minute refractive areas paralleling the periphery develop, and 
radial shadings, which later divide the body usually into from 
eighteen to twenty spores, become apparent. The segmenting 
body is smaller than that of the tertian and quartan parasites, but 
it usually resembles the former as to the arrangement and num- 
ber of the individual segments. 

A marked characteristic of the estivo-autumnal infections is 
the early occurrence of degenerative changes in the invaded 
erythrocytes. These changes, the "erythropyknosis " of the 



MALARIAL FEVER. 



373 



Italian school, consist in the development of a pronounced 
"brassy" appearance of the blood cell, together in many in- 
stances with distinct crenation along its periphery and in various 
portions of its flat surface. Occasionally, there appears to be a 
distinct concentration of the hemoglobin about the parasite, leav- 
ing portions of the corpuscle quite colorless. This corpuscular 
degeneration occurs early, even in those cells occupied by the 
youngest hyaline bodies, and grows more and more marked, as 
a rule, as the parasite matures. Simple decolorization of the 
erythrocyte appears to follow no fixed rule, for segmenting 
bodies have been observed in both perfectly hyaline and in ap- 
parently unchanged corpuscles. In Thayer's experience the rim 
of the blood cell surrounding the parasite has usually been 
entirely devoid of color. 

After the infection has existed for a week or more, examination 
of the peripheral blood, which until now has contained perhaps 
only ring-shaped organisms, reveals the presence of other highly 
characteristic forms of the estivo-autumnal parasite, the round, 
ovoid, and crescentic bodies, all belonging to the crescent group. 
These forms, which are never present in the circulation during 
the first days of the fever, are prone to persist in the blood for a 
long period after the disappearance of the earlier forms of the 
parasite, and even after all the clinical manifestations of the 
attack have vanished. Unlike other forms of the malarial para- 
site, those of the crescent group are peculiarly resistant to the 
effects of the administration of quinine, large doses of this drug 
having in many instances no appreciable effect in causing their 
disappearance from the peripheral circulation. 

Crescents are now generally regarded as of intracellular origin, 
being transformed stages of the full-grown, pigmented, intracel- 
lular spherical bodies which have not been involved in the proc- 
ess of segmentation. These non-segmenting forms continue 
their development within the corpuscle, from which they derive 
more and more pigment, thus causing progressive decolorization 
of their host, until finally all that remains of the corpuscle is a 
thin shell surrounding the crescent. As their growth progresses, 
the parasite first loses its regular spherical contour, then becomes 
drawn out into a long, narrow, spindle-shaped body, which finally 
becomes bent in the shape of a crescent, the convexity of which 
lies next to, and for some distance parallels, one margin of the 
now almost colorless erythrocyte. 

Owing to the fact that the early development of these crescentic 
forms occurs almost exclusively in the deeper circulation, only the 
later phases of their evolution are ordinarily observed in the periph- 



374 



GENERAL HEMATOLOGY. 



eral blood. In fresh blood they appear as highly refractive cres- 
cent-shaped bodies, measuring about 6 or 8 fi from pole to pole, 
and possessing a distinct double outline, as if they consisted of 
a central darker body enclosed in a lighter colored membra- 
nous envelope. Adhering to the concave surface of the crescent 
a more or less distinct "bib," the remnant of the corpuscular host, 
may usually be observed. It varies in color from pale yellow to 
an almost indistinguishable shade of light lemon, yet always, on 
close observation, retaining sufficient of the corpuscular color to 
distinguish it from the parasite to which it is attached. The 
"bib" completely bounds the concavity of the crescent in some 
instances, extending from pole to pole ; in other instances, and 
this is of commoner occurrence, it is of smaller size, extending 
only over the central portion of the concavity. Occasionally 
crescentic bodies totally devoid of all traces of their corpuscular 
host are found, but these forms are rare. The pigment is usually 
arranged in a moderately compact clump in the center of the 
crescent ; less commonly the granules are scattered along the 
long axis ; and very rarely a distinct polar grouping of the pig- 
ment at both ends of the crescent is seen. The pigment gran- 
ules may or may not show active motility. 

The ovoid bodies, which are regarded simply as transitional 
forms of the crescents, are of symmetrically oval shape, and show 
the same refractive protoplasm and apparently double outline ob- 
served in the latter. The pigment, which is generally motionless, 
is arranged in an elongated clump in the center of the ovoid, and 
a partly decolorized bib-like corpuscular attachment apparently 
clings to one side of the body. The long diameter of the ovoid 
body measures approximately 5 or 6 [i and its short axis is about 
2 or 3 fi across. 

The round forms, derived from the crescentic and ovoid bodies, 
are the direct antecedents of the flagellate organisms. They 
appear as perfect spheres, 4 or 5 fi in diameter, either attached 
to a more or less yellowish remnant of the erythrocyte, or lying 
entirely free. Their pigment is prone to form a central wreathed 
or ringed design. 

The approach of flagellation is preceded by unusual activity of 
the central pigment mass, coincidentally with which indications 
of motility about the periphery of the parasite become apparent. 
The flagella, which are finally seen to reach out from different 
points on the periphery of the body, are similar in appearance to 
those of the tertian and quartan organisms. Their size, however, 
is about midway between that of the tertian and quartan forms. 

Degenerative changes of the crescentic, ovoid, and round bodies 



MALARIAL FEVER. 



375 



occur, being evidenced by the development of vacuolization, and 
occasionally by apparent fragmentation. 

Pigmented leucocytes are found in the blood 

Pigmented of all types of malarial infection, and this fact 
Leucocytes and alone, irrespective of the presence of the parasites 
Phagocytosis, themselves, is an extremely valuable diagnostic 
clue to the condition. 

In tertian and quartan infections the large mononuclear and 
polymorphonuclear leucocytes are the pigment-bearing cells, the 
granules being found either scattered in fine masses or in fused 
angular blocks throughout the body of the leucocyte. Although 
both of these forms of leucocytes show this evidence of having 
acted the role of phagocytes, actual visual proof of the performance 
of this function by the mononuclear forms is wanting. The phe- 
nomenon of phagocytosis by the polymorphonuclear leucocytes 
may, however, be watched in the fresh specimen, and these cells 
may be seen to engulf bits of free pigment, flagellate bodies, bas- 
tard forms of extracellular parasites, and even, rarely, true seg- 
menting bodies. Distinct periodicity characterizes the perform- 
ance of phagocytosis in tertian and quartan infections, this process 
being most conspicuous at the time of segmentation, during and 
shortly after the paroxysm, when the extracellular forms of the 
organism are present in the blood in greatest number. Phagocy- 
tosis is sometimes seen during the interparoxysmal interval, when 
only the extracellular forms of parasites which have prematurely 
escaped from their corpuscular host are attacked. 

In estivo-autumnal infections macrophages, derived from the 
spleen, bone marrow, liver, and blood vessel endothelium, act as 
phagocytes, as well as the mononuclear and polymorphonuclear 
cells which alone exercise this function in the regularly intermit- 
tent fevers. Phagocytosis is much less periodical than in tertian 
and quartan infections, for while it is true that pigmented leuco- 
cytes are most numerous in the blood at the time of segmenta- 
tion, it is also true that they may also be observed in great num- 
bers during the interval — a fact which is explained chiefly by the 
practically continuous segmentation which goes on in these infec- 
tions, because of the presence in the blood of multiple groups of 
the parasite. Phagocytosis in estivo-autumnal fever differs from 
that of tertian and quartan infections in that in the former inclu- 
sion of both parasite and corpuscular host may occasionally be ob- 
served — a phenomenon which does not occur in the latter. Thus, 
in addition to free pigment, and extracellular, segmenting, and flag- 
ellate forms, the phagocytic leucocytes are found also to contain 
whole or portions of necrobiotic erythrocytes, some of the latter, 



376 



GENERAL HEMATOLOGY. 



perhaps, enclosing parasites. Osier 1 has observed the phagocy- 
tosis of crescentic forms, and the writer believes he has observed 
the result of this phenomenon in a single instance. (See Plate 
VIII., figure 25.) 

Differential Table of the Malarial Parasites. 



Tertian Parasite. 



Cycle, 48 Hours. 



Hyaline body larger than 
that of quartan and estivo- 
autumnal organisms ; out- 
line indistinct ; ameboid 
movements exceedingly 
active ; long pseudopodia 
common. 



Pigment granules fine, very 
active, and of yellowish 
brown color; more or less 
peripherally arranged. 



Mature parasite about 7 fi in 
diameter. 

Segmenting bodies consist 
of from 15 to 30 segments, 
arranged in an irregular 
racemose figure about one 
or more central pigment 
clumps. 



Preflagellate forms consist 
of swollen, spherical pig- 
mented bodies as large as 
10-12 n in diameter. 



Flagellate form larger than 
that of quartan and estivo- 
autumnal parasite. 

Erythrocyte becomes very 
pale and swollen. 



Quartan Parasite. 



Cycle, 72 Hours. 



Hyaline body smaller than 
that of tertian, but usu- 
ally larger than that of 
estivo-autumnal organ- 
ism ; outline distinct ; 
ameboid movements 
slow, except in early 
forms ; marked pseudo- 
podial branching un- 
common. 

Pigment granules coarse, 
sluggish, and of dark- 
brown color ; peripheral 
arrangement striking. 



Mature parasite about 5 11 
in diameter. 

Segmenting bodies consist 
of from 6 to 1 2 segments, 
arranged in regular ro- 
sette form about a single, 
compact, central pigment 
mass, the latter often be- 
ing radially grouped in 
the early stages of spor- 
ulation. 

Preflagellate forms consist 
of swollen, spherical 
pigmented bodies as large 
as 6-8 ju in diameter. 



Flagellate form smaller 
than that of tertian and 
estivo-autumnal parasite. 

Erythrocyte becomes dark 
and contracted. 



estivo-autumnal parasite 

Cycle, 24 to 48 Hours 
or Longer. 

Hyaline body smaller than 
that of tertian and quar- 
tan organisms ; outline 
very sharp and distinct ; 
ameboid movements ac- 
tive in early stages ; 
ring- and disc-shaped 
forms. 



Pigment granules exceed- 
ingly fine and scanty ; 
may be either motion- 
less or motile ; periph- 
eral arrangement often 
marked. 

Mature parasite from 1.5 
to 7 fi in diameter. 

Segmenting bodies consist 
of from 18 to 20 or more 
segments, arranged 
either as a regular ro- 
sette or irregularly about 
a single compactly fused 
central pigment clump. 



Preflagellate forms consist 
of spherical pigmented 
bodies, 5-6^ in diam- 
eter, and derived from 
crescentic and ovoid 
forms with which they 
are associated. 

Flagellate form smaller 
than that of tertian, but 
larger than that of quar- 
tan parasite. 

Erythrocyte becomes 
brassy and crenated. 



Teclinique of the Blood Examination. For diagnostic purposes 
the fresh, unstained blood film should be invariably preferred to 
the dried, stained specimen, for in the latter not only are the ame- 

1 British Med. Journ., 1887, vol. i., p. 556. 



MALARIAL FEVER. 



377 



boid movements of the parasite and the dancing of the pigment 
necessarily lost, but much of the morphology and the finer struc- 
ture of the organism is also greatly altered. The blood is 
obtained in the usual manner, and a drop used which is small 
enough to insure an exceedingly thin film, consisting of a single 
layer of corpuscles, each lying edge to edge, so that every portion 
of their flat surfaces may be readily searched for foreign bodies. 
Specimens in which most of the cells stand on edge, piled 
together in heaps and rouleaux, are entirely unsuitable, if intra- 
cellular forms of the parasite are being searched for, since in such 
films only the extracellular forms are visible. Thin, even films 
are facilitated by gently heating the slide over an alcohol flame, or 
by instructing an assistant to rub the surface of the slide vigorously 
with a dry towel before making the spread. If the examination is 
likely to be prolonged, it is advisable to ring the cover-glass with 
cedar oil or with vaseline, to prevent crenation of the corpuscles. 

Dried blood films, prepared in the usual way, may be used in 
case the specimens must be sent some distance for examination. 
Such specimens may be stained with various aniline dyes, as 
already directed. Polychrome methylene-blue gives the sharpest 
differentiation of the parasite's histological structure, but solutions 
of thionin and of eosin and methylene-blue also will prove useful. 
(See pages 67 and 69.) 

No magnification can be too great in studying the finer points of 
the malarial parasite, so that a ^ inch oil-immersion objective, 
with at least a i|- inch ocular, should be habitually employed 
for the microscopical examination. While it is frequently con- 
venient to search for individual parasites with a | or a J inch 
lens, one cannot well dispense with an immersion objective in 
distinguishing their finer characteristics. The substage condenser 
and iris diaphragm should be so adjusted that the field is dimly 
illuminated, and not drowned in a flood of white light. When the 
ameboid movements of the parasite are to be studied at length, a 
warm stage is useful, but not essential, if the temperature of the 
room is not too low. 

The best time for the examination is a few hours before the 
onset of the expected paroxysm, at which period it is common to 
find full-grown pigmented organisms, and often an occasional 
segmenting form, if the specimen is from a tertian or quartan in- 
fection. In estivo-autumnal fever relatively large ring- and disc- 
shaped bodies, containing exceedingly delicate pigment granules, 
are usually abundant at this time. Hyaline intracellular forms 
are most numerous in the blood a few hours subsequent to the 
paroxysm, in all three forms of the infection. 



373 



GENERAL HEMATOLOGY. 



The writer would urge the beginner systematically to study the 
development of a group of parasites by examining the blood of a 
single case of malarial fever at frequent intervals between the 
paroxysms. For example, the life history of the tertian parasite, 
from the youngest hyaline form to the segmenter and the flagel- 
late body, may be traced in most cases of tertian fever, if the 
blood is examined every three or four hours, day and night, for a 
period of forty-eight hours. Such a collated series of observa- 
tions, although they entail close and tiresome application for the 
time, will prove more profitable to the student in his comprehen- 
sion of the organism's developmental cycle than dozens of hap- 
hazard examinations made in many different cases at odd times. 

To the unpractised eye a number of artefacts occurring in fresh 
blood specimens may for a time be confused with the malarial par- 
asite, but careful observation linked to an increased familiarity 
with the appearance of the organism and of its counterfeits, will 
eliminate such sources of error. The following are the principal 
objects which require to be differentiated from the malarial par- 
asite : ( i ) The central biconcavity of the normal erythrocytes ; 
(2) morphological changes in the erythrocytes, and (3) hemoconise. 

1. At first glance, the pale central biconcavity of the erythro- 
cyte somewhat resembles the young hyaline tertian parasite, for 
both have an indistinct outline which merges with the surround- 
ing corpuscular substance. But the parasite is rarely in the cen- 
ter of the blood cell, it is actively ameboid, and it possesses a 
characteristic pearly-gray appearance. On the other hand, the 
pale area of the corpuscle is in the center of the normally shaped 
blood cell, it never exhibits ameboid powers, and its appearance 
is clean white or yellowish-white. It is, of course, uncolored in 
the stained specimen. 

2. The morphological changes in the erythrocyte, which may 
be mistaken for malarial organisms, are those produced by vac- 
7tolization y crenation, and fragmentation of these cells. Vacuoles 
appear as highly refractive, clean-cut, spherical bodies which 
possess more or less oscillating, rotary motility, in contrast to 
the dimmer, more vaguely outlined, truly ameboid forms of the 
hyaline malarial parasite. The spicula of crenated red cells may 
in a very dim illumination of the object appear at first glance 
somewhat like the coarse granules of the mature pigmented par- 
asite, but a change of focus and a wider-open diaphragm im- 
mediately dispels the illusion. Fragmentation of the erythro- 
cytes, as the result of thermic influences, may produce a most 
bizarre and peculiar variety of designs, the most confusing of 
which is a sort of flagellate appendage which appears to originate 



MALARIAL FEVER. 



379 



in a fragmented sphere of corpuscular substance, to which it is 
attached. The size of this body, however, is far too small to be 
mistaken seriously for a true malarial flagellate body, for its 
spherical portion, which is unpigmented and tinged with hem- 
oglobin, measures only about 2 [i in diameter ; while the flag- 
ellate appendage, usually single, is represented by a colorless, 
thin line not often longer than 3 or 4 ju, and tremulously motile, 
not ameboid like the flagellum of the malarial body. This 
sort of a flagellate figure is very commonly seen in blood slides 
which have become chilled. 

3. Hemoconice are readily distinguished by their very small 
size, spherical contour, and glistening, fat-like appearance. It 
sometimes happens that one of these granules of "blood-dust," 
in its Brownian excursion across the field of the microscope, lies 
over the flat surface of an erythrocyte, simulating for the mo- 
ment, a small, hyaline, intracellular parasite. It seems probable, 
also, that one of these granules, observed just at the instant it 
crosses the rim of the blood cell, has been mistaken for a hyaline 
spore in the act of invading an erythrocyte, by those who be- 
lieve that they have witnessed this remarkable phenomenon. 

Well-marked anemia, developing early during 
Hemoglobin the course of the disease, and proportionate in 
and degree to the severity of the attack, is a con- 
Erythrocytes. spicuous clinical sign in the malarial fevers. 

Dionisi, 1 Thayer, 2 and other authors have ob- 
served that a loss of hemoglobin and a diminution in the number 
of erythrocytes occur after every paroxysm, this being due largely 
to the destruction of immense numbers of parasite-containing cor- 
puscles by the maturation of the organisms, and in part to the 
presence in the blood of other substances destructive to the un- 
invaded red cells. The loss is especially marked after the early 
paroxysms, being of slighter degree after those occurring later 
in the course of the disease. On the other hand, during the 
paroxysm a tendency on the part of the red corpuscles to increase 
in number has been noted. 

The loss is more moderate in the regularly intermittent tertian 
and quartan types of malaria than in the estivo-autumnal form. 
In the former types, the regenerative powers of the blood are 
usually prompt and vigorous, so that the normal number of cells 
is almost restored by the onset of the succeeding paroxysm. It 
is owing to this fact that repeated paroxysms must occur before 
the anemia becomes striking. 

1 Lo Sperimentale, 1891, f. iii. and iv., p. 284. 
2 Loc. cit. 



3 8o 



GENERAL HEMATOLOGY. 



In the estivo-autumnal form the loss is far greater, a decrease 
of 500,000 or more corpuscles per cubic millimeter sometimes 
occurring after a single paroxysm, such a marked loss as this being 
associated especially with cases in which excessive numbers of 
parasites are present in the blood. Even in non-febrile cases of 
larval malarial fever, Marchiafava and Bignami 1 have observed 
more or less anemia. Organisms of the crescent group appear 
to exert no influence in causing diminution in the number of 
erythrocytes. Regeneration of the blood is slow in the estivo- 
autumnal fever, so that the loss of hemoglobin and of corpuscles 
is not made up during an inter-paroxysmal interval, in consequence 
of which more marked and graver anemias are commoner than 
in the tertian and quartan fevers. If the anemia is markedly 
developed during the early stages of the infection, the corpus- 
cular decrease is aggravated slightly, if at all, by the following 
paroxysms. 

In malarial hemoglobinuria an enormous destruction of cor- 
puscles occurs, " a destruction," in the words of Thayer, 2 " too 
great, probably, to be dependent wholly on the disintegration of 
parasitiferous elements. We are compelled ... to suppose 
the existence of some condition which renders the uninfected red 
blood corpuscles unusually vulnerable, possibly some change in 
the blood serum by which its isotonicity is markedly disturbed." 

Usually the hemoglobin loss is relatively greater than the cor- 
puscular decrease, moderately low color indices being the general 
rule, but in some cases both are parallel. In estimates made 
by the author in twenty-two cases of malarial fever, nearly all 
of the tertian type, the hemoglobin averaged 60.8 per cent, of 
normal, ranging, in the individual case, from 30 to 80 per cent. 
The color index in these cases averaged 0.87, the extremes being 
0.55 and 1.5 1. 

The variations in hemoglobin were as follows : 



Between 80-90 per cent, in 3 cases. 



70-80 
60-70 
50-60 
40-50 
30-40 



Average 
Highest 
Lowest : 



" 6 

" 5 
" 2 

" 4 
" 2 

60.8 per cent. 
80.0 " 
30.0 " 



1 Loc. cit. 
2 Loc. cit. 



MALARIAL FEVER. 



381 



The loss of corpuscles varies within wide limits, being most 
marked in severe and in long-standing cases. Counts as low as 
500,000 per cubic millimeter have been reported, 1 and the num- 
ber falls to from 1,000,000 to 2,000,000 in a considerable pro- 
portion of cases. In the above series, the average of the twenty- 
two counts showed 3,481,818 erythrocytes per cubic millimeter, 
individual cases varying from 1,410,000 to 4,880,000. The range 
of the counts is shown thus, in tabular arrangement : 

Between 4,000,000-5,000,000 in 11 cases. 
" 3,000,000-4,000,000 " 2 " 
" 2,000,000-3,000,000 " 6 " 
" 1,000,000—2,000,000 " 3 " 

Average : 3,481,818 per cb. mm. 
Highest: 4,880,000 " " 
Lowest: 1,410,000 " " 

In seven cases clinically designated as "malarial cachexia," in 
which parasites were not found in the circulating blood, the fol- 
lowing results were obtained : hemoglobin ranged from 40 to 52 
per cent., the average being 45.5; color index, from .41 to 1. 13, 
averaging .66 ; and erythrocytes, from 2,300,000 to 4,861,000 
per cubic millimeter, with an average of 3,406,250. 

As regeneration of the blood, which is generally slow, takes 
place, the normal percentage of hemoglobin is reached more 
slowly than that of the corpuscles — in fact, in some instances of 
post-malarial anemia subnormal hemoglobin percentages persist 
for indefinite periods after convalescence has been established. 

Histological changes in the erythrocytes are marked in relation 
to the severity of the anemia. Pallor of the corpuscles is often 
conspicuous, and poikilocytosis and deformities of size are pres- 
ent in severe cases. In such instances small percentages of nor- 
moblasts, and of atypical nucleated forms are not infrequently 
found, sometimes in association with an occasional megaloblast. 
In severe cases both polychromatophilia and basic granular de- 
generation of the erythrocytes are familiar findings. 

The following four types of post-malarial anemia are distin- 
guished by Bignami and Dionisi. 2 

1. Anemise in which examination of the blood shows altera- 
tions similar to those observed in secondary anemise, from which 

^elsch: Archiv. de Physiologie, 1875, vol. ii., p. 690. Ibid., 1876, vol. iii., 
p. 490. 

2 Centralbl. f. Allg. Path. u. path. Anat., 1894, vol. v., p. 422. (Quoted from 
Thayer and Hewetson : "The Malarial Fevers of Baltimore," Baltimore, 1895, p. 
58.) 



3 82 



GENERAL HEMATOLOGY. 



they differ only in that the leucocytes are diminished in number. 
The greater part of these cases go on to recovery ; a few, without 
any further change in the hematological condition, pursue a fatal 
course. 

2. Anemiae in which the examination of the blood shows altera- 
tions similar to those seen in pernicious anemia — presence of gigan- 
toblasts. These cases end fatally. 

3. Anemiae which are progressive, as a result of the lack of 
compensation by the marrow for losses brought about by the 
infection. At autopsy the marrow of the long bones is found to 
be wholly yellow, while the marrow of the flat bones is also poor 
in nucleated red corpuscles. 

4. Chronic anemiae of the cachectic, which differ from the above- 
mentioned types by clinical and anatomical characteristics in that 
the special symptoms of malarial cachexia prevail, while one ob- 
serves, post-mortem, a sort of sclerosis of the bone marrow. The 
marrow of the long bones is red and of an increased con- 
sistency; the giant cells are very numerous and many are ne- 
crotic; the nucleated red blood corpuscles are very rare, and 
the colorless polymorphonuclear corpuscles are present in small 
numbers. 

Distinct leucopenia, or at least an absence 
Leucocytes, of leucocytosis, is almost invariably found in the 
uncomplicated case of malarial fever, the excep- 
tions to this general rule occurring during the grave paroxysms 
of the pernicious type of fever. 

The subnormal range of the leucocytes in malarial fever was 
early noted by Kelsch, 1 and has been repeatedly confirmed by 
other investigators since the former's statement of the fact. 
Billings, 2 in particular, has carefully studied this question, and 
his examinations, 100 in number, show that the number of leu- 
cocytes averaged 4,323 per cubic millimeter, or a decrease of 
about 38 per cent, below normal. In 71 counts made by this 
reporter in 16 cases, in order to determine the effects of the 
malarial paroxysms on these cells, it was found that during the 
early part of the paroxysm their number gradually increased, 
the maximum being reached, as a rule, two or three hours after 
the chill. Following this maximum increase the number steadily 
and progressively decreased, hour by hour, until the minimum 
was reached during the period of subnormal temperature, at the 
end of the paroxysm. During the afebrile interval the number 
of leucocytes is distinctly subnormal, but it rises slightly again 

1 Loc. cit. 

2 Johns Hopkins Hosp. Bull., 1894, vol. v., p. 89. 



MALARIAL FEVER. 



383 



just before the onset of the following chill, so that the average 
count is slightly higher immediately before the chill than during 
the rest of the interval. 

In the author's series, above referred to, the average of 18 
counts showed 5,211 leucocytes per cubic millimeter, the lowest 
count being 2,000, and the highest 11,600. All these counts 
were made during the interval between the paroxysms, in un- 
complicated cases, so far as it was possible to determine. 

The counts ranged as follows : 

Above 10,000 in 2 cases. 

Between 8,000-10,000 " 3 " 
11 6,000- 8, poo " 2 " 
11 4,000- 6,000 " 6 " 
" 2,000- 4,000 " 5 " 
Average : 5,211 per cb. mm. 
Highest: 11,600 " " " 
Lowest: 2,000 " " " 

In the 7 cases of " malarial cachexia " the number of leuco- 
cytes to the cubic millimeter ranged from 4,500 to 44,000, the 
average being 16,971. Five of these cases had distinct leuco- 
cytosis, a condition believed by Thayer to occur in some of the 
post-malarial anemias, usually those following short-lived infec- 
tions. 

Relative lymphocytosis, sufficiently decided to become a striking 
characteristic of the condition, is practically a constant qualitative 
change. As a rule, the increase affects chiefly the large lympho- 
cytes. Stephens, 1 in a recent study of "blackwater fever," found 
that this type of cells often constituted 20 per cent., 30 per cent., 
or even 50 per cent, of the total number of leucocytes ; further- 
more, he states that this relative increase bears an inverse relation 
to the temperature curve, being least marked during the pyrexia, 
and greatest during the periods of apyrexia. This feature persists 
in some cases with leucocytosis, as well as in those with leuco- 
penia. The percentage of eosi?iophiles is, as a rule, subnormal, 
and this variety of cells is frequently absent ; more rarely they 
are slightly increased, especially in some of the post-malarial 
anemias. Myelocytes in small numbers are very commonly 
found, in the writer's experience, especially in estivo-autumnal 
infections, and in cases with pronounced anemia. In 9 differential 
counts, made in cases of the series above referred to, the relative 
percentages of the different forms of leucocytes averaged as 
follows : 

1 Lancet, 1901, vol. L, p. 848. 



3§4 



GENERAL HEMATOLOGY. 



Small lymphocytes 15.33 P er cent. 

Large lymphocytes and " transitional " forms. 15.94 " " 

Polynuclear neutrophils 67.00 " " 

Eosinophiles 83 " " 

Myelocytes 51 " " 

Practically the same figures were obtained from the similar ex- 
amination of 3 cases of anemia associated with malarial cachectic 
conditions. 

The blood plaques are greatly decreased in number, as in other 
febrile conditions. 

The detection of the specific parasite in the 
Diagnosis, circulating blood is proof positive of malarial 
fever, the exact type of which may be determined 
by close study of the organism's peculiarities. Even if nothing 
more definite than pigmented leucocytes is found, the evidence 
is strongly in favor of some form of paludism. The progressive 
anemia, and the leucopenia involving a relative decrease in the 
polynuclear neutrophiles, are also valuable side-lights on the 
diagnosis. An obscure intermittent fever which shows leucocy- 
tosis is almost certainly not malarious. 

The chills and pyrexia of sepsis and of tuberculosis are not in- 
frequently misinterpreted as symptoms of malarial fever. In 
septicemia leucocytosis is usually found, but even should the 
leucocytes not be increased in number, they fail to show the 
relative lymphocytosis of malarial blood. In pure tuberculosis 
the blood-picture of malaria may be counterfeited, in so far as the 
quantitative and qualitative leucocyte changes are concerned, and 
in such instances the parasite must be demonstrated to settle the 
diagnosis. The same leucocyte changes also occur in enteric 
fever, the differentiation of which has been alluded to above. 
(See page 331.) It maybe added that in those rare instances of 
coincident typhoid and malaria the blood of the same individual 
may contain parasites and give a positive serum reaction with the 
Eberth bacillus. 

XXXVII. MALIGNANT DISEASE. 
Carcinoma. 

There is no deviation from normal in the coagu- 
General lability and the amount of fibrin, except in the 
Features, event of ulcerative and inflammatory changes 
affecting the tumor, but, should these conditions 
be present, coagulation may occur with abnormal rapidity, and 
the density of the fibrin network almost invariably increases. The 



MALIGNANT DISEASE. 



385 



specific gravity may or may not be subnormal, according to whether 
or not the percentage of hemoglobin, which it parallels, is reduced. 
The alkalinity of the blood is almost always decreased in gastric 
cancer, according to Krokiewicz. 1 

Relatively large amounts of sugar (as high as 3 parts per 
1,000) have been found in the blood of patients suffering from 
various forms of carcinoma, especially visceral cancer, in contra- 
distinction to more superficial growths, involving, for example, the 
skin and mucous membranes. In no other disease except diabetes 
has more than one-third of the above-named quantity of sugar been 
detected in the blood, according to the analyses made by Trinkler. 2 

Examination of the blood for the detection of a specific parasite 
of cancer has thus far proved unconvincing, although much care- 
ful work has been done with this purpose in view. Gaylord 3 has 
recently described protozoa similar to the bodies previously dis- 
covered by Russell 4 and by Plimmer, 5 to which he ascribes 
specific properties, claiming " in all cases of carcinoma and sarcoma 
thus far examined in which cachexia was well marked, that the 
organisms can be detected in the peripheral blood." This an- 
nouncement, while of great interest and importance, must receive 
corroboration by other investigators before it can merit general 
acceptance. The careful studies of 33 cases of cancer, recently 
completed by Maragliano, 6 have apparently disproved the state- 
ments of a number of authors, who claimed to have cultivated 
blastomycetes from the circulating blood in this disease. 

During its incipiency carcinoma gives rise to 
Hemoglobin practically no changes in the erythrocytes or their 
and hemoglobin content, or at the most causes simply 

Erythrocytes, a moderate diminution in the latter. As the 
disease progresses and extends, and as the 
cachexia of the patient becomes more pronounced, a secondary 
anemia develops, attaining but a moderate degree in some 
instances, but in others becoming so extreme as to simulate in 
some particulars true pernicious anemia. Since the hemoglobin 
loss usually anticipates the cellular decrease, the blood-picture of 
early cancer not infrequently resembles that of chlorosis. Later, 
however, these conditions may be reversed, so that the index 
rises. In the author's experience, the average hemoglobin loss 

1 Archiv. f. Verdauungskrankh. , 1900, vol. vi., p. 25. 
2 Centralbl. f. d. med. Wissensch., 1890, vol. xxviii., p. 498. 

3 Am. Journ. of Med. Sc., 1901, vol. cxxi., p. 503. 

4 British Med. Journ., 1900, vol. ii., p. 1356. 

5 Practitioner, 1899, vol. lxvii., p. 430. 

6 Gaz. degli Osp. e. d. Clin., 1900, vol. xxi., p. 1538. Also, Sem. med., 1901, 
vol. xxi., p. 63. 

25 



3 86 



GENERAL HEMATOLOGY. 



has amounted to somewhat more than 40 per cent., and the 
erythrocyte decrease to about 25 per cent, of normal. The color 
index tends to range moderately low, usually from 20 to 30 points 
below the standard of health. It averaged 0.76 for the 54 cases 
grouped below. As just intimated, it is generally lower in the 
early than in the late stages of the disease. In operative cases of 
carcinoma it has been observed that the regeneration time of the 
hemoglobin averages at least two-thirds longer than in other 
diseases treated surgically, and that the loss of hemoglobin after 
operation is usually not less than 1 5 per cent. Bierfreund 1 finds 
that the percentage of hemoglobin after the removal of the tumor 
never equals that found before the operation. 

The oligocythemia is occasionally most striking, for in some 
cases the counts may range as low as between 1,000,000 and 
2,000,000, such a degree of decrease apparently being most com- 
monly found in septic cases, and in gastric cancer. F. P. Henry's 
statement 2 that he has never seen a case of the latter disease in 
which the erythrocytes fell below 1,500,000 to the cubic milli- 
meter has been generally corroborated, although counts below 
this figure have been occasionally reported. In one of the cases 
of cancer of the stomach included in the table given below the 
count was 1,001,000 per cubic millimeter, and the hemoglobin 
percentage 50. 

Polycythemia may occur as a temporary condition in gastric 
and esophageal cancer, as the result of blood concentration due 
to vomiting, to diarrhea, or to lack of ingested fluids. In such 
instances the number of erythrocytes not uncommonly exceeds 
6,000,000 or 7,000,000 per cubic millimeter, and, exceptionally, 
even a higher figure. 

The following table illustrates the alterations in the amount 
of hemoglobin and number of erythrocytes, as determined by 
the examination of 54 cases of various forms of carcinoma. 

Hemoglobin Percentage. Erythrocytes per cb. mm. 

From 80-90 in 2 cases. Above 5,000,000 in 4 cases. 

70-80 " 10 " From 4,000,000-5,000,000 " 21 " 
60-70 11 19 " " 3,000,000-4,000,000 " 18 11 

50-60 " 9 " " 2,000,000—3,000,000 " 6 " 

40-50 " 7 " " 1,000,000-2,000,000 " 5 " 

30-40 " 5 " 
20-30 " 2 " 

Average : 58.4 per cent. Average : 3,815,073 per cb. mm. 

Maximum: 28.0 " Maximum: 5,340,000 " " " 

Minimum: 23.0 " Minimum: 1,001,000 " " " 

1 Langenbeck' s Archiv., 1890-91, vol. xli., p. I. 
2 Archiv. f. Verdauungskrankh. , 1898, vol. iv., p. I. 



MALIGNANT DISEASE. 



387 



In gastric cancer Osier and McCrae 1 report an average of 49.9 
per cent, of hemoglobin in 52 cases, and an average erythrocyte 
count of 3,712,186 in 59 cases. In two cases the count was less 
than 1,500,000. An average color index of 0.63 was found in 
this series. 

Deformities of shape and of size are marked in relation to the 
grade of the anemia which exists. Poikilocytes may be quite as 
numerous and as striking as in true pernicious anemia, while the 
alterations affecting simply the size of the cells tend toward 
micro- rather than megalocytosis. Polychromatophilia and baso- 
philic degenerative changes are frequently to be seen in grave 
cases with marked cachexia. 

Erythroblasts are very common, especially in cancer with 
decided cachexia and high-grade anemia, but their occurrence is 
by no means limited to such cases, as they may also be found in 
blood which shows but trifling quantitative deterioration. It may 
be stated as an accepted fact that nucleated erythrocytes occur in 
cancer more frequently than in any other variety of secondary 
anemia, except that accompanying sarcoma. 

Normoblasts are generally found to the exclusion of other 
forms, although in an exceptionally grave case an occasional 
megaloblast and atypical " mesoblast " may be encountered. 
The important point to be remembered is that cells of the adult, 
normoblastic type invariably predominate, since megaloblasts, 
when present, are never so numerous as normoblasts. 

Leucocytosis is a frequent but not a constant 

Leucocytes, feature of the blood-picture in carcinosis, for 
quite as many cases are encountered in which the 
number of leucocytes is normal as those in which an increase 
prevails. Judging from the statistics of patients treated in the 
German Hospital, leucocytosis is present in less than one-half of 
all forms of cancer, or in 44.4 per cent. In general terms, it may 
be said that tumors characterized by active inflammatory changes, 
by hemorrhage, by rapid growth, or by extensive metastases are 
accompanied by a well-marked leucocyte increase, while non-in- 
flammatory, slowly developing, localized tumors do not raise the 
count. Thus, a large carcinoma of the liver or kidney, for in- 
stance, may cause a leucocytosis of 30,000 or 40,000 to the 
cubic millimeter, while a small, limited skin cancer may exist 
without provoking the slightest increase. Thorough extirpation 
of the growth is followed by a decline in the leucocytosis, the 
normal count being reached by the time the wound has entirely 
healed. Hayem 2 is the authority for the statement that in mam- 

1 "Cancer of the Stomach," London and Phila., 1900, p. 115. 
2 Loc. cit. 



3 88 



GENERAL HEMATOLOGY. 



mary cancer recurrence of the growth after its removal may be 
detected by a reappearance of the leucocytosis, which antedates 
all other physical signs. The constancy of this change, as well 
as the question of its occurrence in cancer involving other struc- 
tures, still remains to be investigated. 

It seems reasonable to attribute the origin of cancer leuco- 
cytosis chiefly to the presence of inflammatory changes in the 
tissues in the neighborhood of the growth, although in some in- 
stances it seems possible that positive chemotaxis may be ex- 
cited by the absorption of toxines derived from the breaking down 
of the neoplasm itself. The strength of the patient's powers of 
resistance as a determining factor of the increase must also be 
taken into account in this as in other diseases. 

In the writer's experience, leucocytosis is most constant in 
cancer of the breast, most striking in cancer of the liver, least 
frequent in cancer of the uterus, and least conspicuous in cancer 
of the stomach. In cancer of the esophagus absence of leuco- 
cytosis is the rule, while in many cases a decided leucopenia may 
exist. 

The 54 cases on the study of which the above observations 
are based may be summarized as follows : 



Seat of 
Growth. 


Number of 
Cases. 


Number and Percentage 
of Cases with Leucocytosis. 


Average 
Count. 


Maximum 
Count. 


Minimum 
Count. 


Stomach. 

Uterus. 

Rectum. 

Breast. 

Liver. 


23 
IO 

8 

7 
6 


* 9 or 39.1% 
2 or 20.0% 

4 or 50.0% 

5 or 71.4% 
4 or 66.6% 


8,163 
9,380 
10,700 
14,407 
18,733 


14,000 
24,000 
l6,000 
31,500 
40,800 


I,000 

4,5°° 
6,000 
8,000 
8,000 


In cancer of the stomach digestion leucocytosis is usually, though 
by no means invariably, absent. The frequency with which this 
phenomenon is absent is shown by the following compilation of 
the data of various authorities who have studied this question : 


Author. 


Number of 
Cases. 


Absent. 


Present. 




24 
22 


21 


3 
IO 


Osier and McCrae 


12 








20 


19 
18 


I 


Schnever 






18 


O 




17 
17 


15 
13 

6 


2 


Krokiewicz 


4 








II 


5 


Hartung 


IO 


10 


0 


Miiller 


5 


5 


0 










144 


119 


25 



MALIGNANT DISEASE. 



389 



These figures, referring to 144 cases, show that digestion leu- 
cocytosis is absent in 82.6 per cent, of gastric carcinomata. But 
the presence of the phenomenon in practically two cases out of 
every ten is sufficient to weaken materially the former belief that 
absence of digestion leucocytosis is a diagnostic sign of this 
disease. Furthermore, it has also been shown by Hoffman 1 and 
others that the sign may be absent in a number of other diseases 
of the stomach, as well as in some apparently healthy individuals. 

Differential counts usually show percentages of polynuclear 
neutrophils s ranging between 80 and 90, with a corresponding 
decrease in the large and small lymphocytes, in cases with leu- 
cocytosis, and not infrequently also in those without. This 
change is not to be considered constant, since relatively high 
percentages of lymphocytes, especially of the large variety, have 
occasionally been observed. The eosinophiles are usually de- 
creased, or, indeed, they may be absent in cases with pronounced 
leucocytosis ; in a certain proportion of cases, in spite of the ab- 
normally high leucocyte count, their relative percentage remains 
within the limits of health. Myelocytes are extremely common, 
small numbers of these cells (usually not higher than a fraction 
of one per cent.) occurring in at least a majority of all cases of 
cancer. The presence of a few basophiles is sometimes to be 
noted, particularly often in association with conspicuously high 
leucocytoses. 

Sarcoma. 

The changes affecting the fibrin, the rate of 
General coagulation, and the specific gravity of the blood 
Features, are similar to those prevailing in cancer, and 

therefore require no further mention. 
In contrast to the hyperglycemia of carcinoma, the researches 
of Trinkler, above referred to, tend to show that in sarcoma no 
increase above normal in the amount of sugar in the blood can 
be detected. Bacteriological examinations of the blood have thus 
far given no definite results. 

The changes in the hemoglobin and erythro- 
Hemoglobin cytes are not materially different from those found 
and in cancer, for the genesis of the blood deteriora- 
Erythrocytes. tion is doubtless similar in all forms of malignant 
disease. Some authors believe that the anemia 
tends to reach a higher degree in sarcoma than in carcinoma, 
but the truth of this contention certainly does not appear to be 
indisputably established. In the writer's experience, unfortu- 

1 Zeitschr. f. klin. Med., 1898, vol. xxxiii., p. 460. 



390 



GENERAL HEMATOLOGY. 



nately most limited in so far as it relates to sarcoma, the inten- 
sity of the anemia is practically similar in both these forms of 
neoplasms, or, if anything, somewhat more striking in cancer, 
both individually and on the average. In a series of 14 cases of 
sarcoma the hemoglobin averaged 63.5 per cent., ranging from a 
minimum of 42 to a maximum of 83 per cent. ; and the average 
count of the erythrocytes was 3,966,714 per cubic millimeter, 
with 2,510,000 and 5,400,000 as the lowest and highest counts, 
respectively. The color index in these cases averaged 0.80. The 
hemoglobin percentage ranged thus : 80-90 in 2 ; 70-80 in 
3 ; 60-70 in 2 ; 50-60 in 4 ; and 40-50 in 3 cases. The eryth- 
rocyte count was as follows : above 5,000,000 in 2 ; 4,000,- 
000-5,000,000 in 4 ; 3,000,000-4,000,000 in 7 ; and 2,000,000- 
3,000,000 in a single case. 

Poikilocytes, micro- and megalocytes (particularly the former), 
and atypically stained cells are common in cases with pronounced 
anemia, and in such instances erythroblasts, the majority of which 
are always normoblasts, are also to be looked for. 

Leucocytosis, while inconstant in sarcoma, is 
Leucocytes, without doubt more frequently associated with 
this lesion than with carcinoma. Statistics have 
also been advanced to demonstrate that the counts range 
higher than in cancer, but the cases on record are still far too 
few to warrant this conclusion. The behavior of the leucocytes 
in both forms of malignant disease is probably influenced by the 
same group of factors. In the cases summarized in the preced- 
ing pages, leucocytosis was found in 24 of the 54 carcinomata, 
or in 44.4 per cent., and in 9 of the 14 sarcomata, or in 64.2 per 
cent. In the latter the counts varied between 7,000 and 40,000, 
and averaged 13,276 per cubic millimeter. They ranged as fol- 
lows : 5,000-10,000 in 4 ; 10,000-15,000 in 7 ; 1 5,000-20,000 
in 1 ; and above 20,000 in 2 cases. 

The increase usually involves a large absolute and relative 
gain in the polynuclear neutrophils, at the expense of the lympho- 
cytes, although in an occasional instance the latter reach a dispro- 
portionately high percentage, while the former decline to a sub- 
normal figure. It may be added that either of these differential 
changes may also occur in the absence of an increase in the total 
number of leucocytes. The percentage of eosinopliiles is usually 
subnormal, and not infrequently these cells may be searched for 
in vain. Rarely, marked eosinophilia has been reported, by com- 
petent authorities, in sarcomata with bone metastases, but such 
findings are by no means constant. In the six cases of osteosar- 
comata of which the writer has reliable differential count records, 



MALIGNANT DISEASE. 



391 



the eosinophiles were absent in 5, while in the sixth their relative 
percentage was but 0.5, in a total leucocyte count of 10,000 per 
cubic millimeter. Small numbers of myelocytes are to be ob- 
served as frequently as not, these cells being about as common 
and as numerous as they are in cancer — a remark which is also 
true of basophiles. 

The clinical resemblance between certain forms 
Diagnosis, of malignant disease (especially those in which 
the lesion remains obscure or undemonstrable) 
and pernicious anemia is often very close, on account of the 
striking degree of cachexia apparent in both. But the blood 
changes found in these two conditions, although similar in some 
respects, are sufficiently characteristic to afford the necessary 
diagnostic clues. These differences, already referred to in a pre- 
ceding section, may, for the sake of emphasis, be expressed as 
follows : 

Malignant Disease. Pernicious Anemia. 

Color index usually moderately Color index almost always 

low. high. 
Oligocythemia usually marked. Oligocythemia invariably ex- 
treme. 

Tendency toward microcytosis. Tendency toward megalocy- 

tosis. 

Erythroblasts common, normo- Erythroblasts constant, mega- 
blasts always predominating. loblasts always predominat- 
ing. 

Leucocytosis common. Leucocytosis rare. 

Lymphocytosis rare. Lymphocytosis common. 

It is to be noted that of the above changes, but one is charac- 
teristic — the invariable predominance of megaloblastic cells in 
pernicious anemia and their minority or absence in those cases of 
malignant disease in which nucleated erythrocytes are found. 

Should a doubt arise as to whether a tumor is benign or ma- 
lignant in character, the fact is to be remembered that the pres- 
ence of a persistent leucocytosis, especially if accompanied by 
anemia, is decidedly in favor of its malignancy. Should it be 
necessary to distinguish between a malignant growth and an 
obscure pus focus with sepsis, the blood examination, aside from 
culturing, is useless, since both leucocytosis and hyperinosis may 
or may not exist in either condition ; if, however, bacteriological 
findings are positive, the existence of a septicemia is obvious. 

As a means of differentiating carcinomata and sarcomata, the 
chemical examination of the blood for sugar should prove of the 
greatest clinical value, if further research substantiates the claims 



39 2 



GENERAL HEMATOLOGY. 



made that hyperglycemia is constant in the first, and absent in 
the second, type of neoplasms. 

As a means of distinguishing gastric cancer from gastric ulcer, 
the blood count is unfortunately of doubtful utility. The pres- 
ence of a persistent, well-marked leucocytosis is a very significant 
sign of cancer, since in ulcer the count is not increased, except 
as the result of hemorrhage, perforation, or digestion. On the 
other hand, an absence of leucocytosis is of no value in determin- 
ing which condition is present, owing to the fact that no increase 
occurs in a large proportion of stomach cancers. Recent inves- 
tigations have fully corroborated Lowit's view, that the absence 
of digestion leucocytosis in gastric cancer has about the same 
diagnostic value as the absence of hydrochloric acid and the 
presence of lactic acid. 

The chief points of distinction in the blood-pictures associated 
with the two diseases in question are illustrated by this table : 

Gastric Cancer. Gastric Ulcer. 

Anemia usually marked. Anemia usually moderate, ex- 

Erythroblasts common. cept after hemorrhage. 

Leucocytosis common. Eiythroblasts rare. 

Absence of digestive leucocy- Leucocytosis rare. 

tosis the rule. Absence of digestive leucocytosis 

the exception. 

If the diagnosis lies between carcinoma, amyloid disease, gum- 
ma, and echinococcus of the liver, the presence of a leucocytosis 
suggests the former ; should it lie between cancer and hypertrophic 
cirrhosis of the liver, high leucocytosis (30,000 or more) is 
strongly in favor of the former, since although the leucocytes 
may be increased moderately in this variety of cirrhosis, they do 
not reach a strikingly high figure. Hyperinosis, if present, is also 
a sign suggestive of cancer, rather than of these other liver dis- 
eases. 

XXXVIII. MALIGNANT ENDOCARDITIS. 

The blood changes in malignant or ulcerative 
General endocarditis are essentially those of a grave sep- 
Features. ticemia, described elsewhere, and do not, there- 
fore, require extended consideration in this place. 
According to the studies of Grawitz, 1 Kraus, 2 Sittman, 3 Kiih- 
nau, 4 James and Tuttle, 5 Thayer and Lazear, 6 and others, the 

1 Charite-Annal., 1894, vol. xix., p. 154. 
2 Zeitschr. f. Heilk., 1896, vol. xvii., p. 117. 
3 Deut. Archiv. f. klin. Med., 1894, vol. liii., p. 323. 

4 Zeitschr. f. Hyg. u. Infectionskr. , 1897, vol. xxv., p. 492. 

5 Med. & Surg. Report of the Presbyterian Hosp., N. Y., 1898, vol. iii., p. 44. 
6 Journ. of Exper. Med., 1899, vol. iv., p. 81. 



MALIGNANT ENDOCARDITIS. 



393 



chances of securing definite results from bacteriological examina- 
tion of the blood are fairly good in this disease. An analysis of 
these authors' work shows that various micro-organisms, notably 
pneumococci, gonococci, streptococci, and staphylococci, are 
demonstrable by culture of the peripheral blood in about one 
case in every three. 

The loss of hemoglobin and erythrocytes is 
Hemoglobin likely to be marked, and, in acute cases, ex- 
and tremely rapid and often most excessive — some- 
Erythrocytes. times as great as in typical pernicious anemia. 

Structural degenerative changes are common, as 
in any severe anemia, and in many acute cases hemoglobinemia 
may be observed. As a rule, the loss of hemoglobin and eryth- 
rocytes is not markedly disproportionate, so that moderately 
subnormal color indices are commonest. 

The following counts, by Dr. Uhle, of a profoundly septic 
patient at the German Hospital, illustrate the striking degree of 
anemia, as well as the intermittent and moderate leucocytosis 
which may develop in a grave case : 



Date. 


Hemoglobin Percentage. 


Erythrocytes percb. mm. 


Leucocytes per cb. mm. 


II- 4-99 


3 A 


1,590,000 


8,000 


II- 8-99 


26 


1,243,000 


8,400 


II-II-99 


30 


2,010,000 


I2,8oO 


II-16-99 


28 


I,8lO,000 


8,000 


II-20-99 


19 


2,130,000 


14,000 


II-25-99 


24 


2,170,000 


12,800 


12- I-99 


25 


1,710,000 


9,600 


12- 5-99 


35 


2,750,000 


l6,000 


I2-I6-99 


41 


3,530,000 


7,200 


I2-27-99 


36 


2,330,000 


4,800 


I- 5-00 


50 


3,350,000 


8,000 


I-II-OO 


38 


2,760,000 


4,000 



An increase in the number of leucocytes, more 
Leucocytes, commonly moderate than marked, and character- 
ized by a high percentage of polynuclear neutro- 
philes, is the usual finding, except in profoundly septic patients, 
in whom the count may be normal or subnormal during the 
greater part of the illness, as shown by the above table. Ab- 
sence of leucocytosis is not infrequent in this disease, doubtless 
because in a large proportion of cases the depressant effects of 
the poison predominate. In no other infection is a better illus- 
tration offered of the relationship between the behavior of the 
leucocytes, the intensity of the disease, and the patient's powers 
of reaction. Occasionally, a striking preagonal increase develops, 



394 



GENERAL HEMATOLOGY. 



or, on the contrary, death may be ushered in by a decided leuco- 
penia. 

In many instances the diagnosis of malignant 
Diagnosis, endocarditis is materially facilitated by the blood 
examination, and in some it can be made only 
by this means. A positive result from blood culturing at once 
gives a definite clue to the real character of the disease, and this 
procedure should be undertaken in every doubtful case. Malig- 
nant endocarditis with marked constitutional symptoms is perhaps 
most frequently confused with enteric fever y and occasionally with 
malarial fever. Both of these infections may be excluded, if a 
leucocytosis exists, unless, of course, this sign is obviously due 
to some complication. It should also be remembered that in 
malignant endocarditis the anemia develops early and tends to 
attain a marked degree with great rapidity, while in the other two 
fevers it does not become striking until the post-febrile stage of 
the disease is reached. No comment is necessary on the value 
of obtaining a positive serum reaction or of detecting the malarial 
parasite, as a means of distinguishing this trinity of infections. 

XXXIX. MALTA FEVER. 

Most cases are accompanied by a moderate, progressive second- 
ary anemia, becoming most marked at about the end of the febrile 
period, and involving, according to Bruce, 1 an average loss of 
about 1,500,000 erythrocytes to the cubic millimeter. The most 
severe anemia is found in cases complicated by profuse epistaxis 
and hemorrhage from the bowel, but those in which these symp- 
toms are absent may show simply a slight oligochromemia, as 
demonstrated by a case studied by Musser and Sailer. 2 Frank 
leucocytosis does not develop, except as the result of hemorrhage, 
but occasionally the number of leucocytes is slightly increased — 
to about 12,000 or 13,000 per cubic millimeter. Charles 3 states 
that during the acute stages of the infection he has found a 
notable relative increase in the large lymphocytes. 

Bruce 4 has not succeeded in finding the micrococcus militensis 
by antemortem bacteriological examination of the blood, although 
he has obtained this organism in pure culture by aspiration of the 
spleen. Wright and Smith 5 discovered that the blood serum of 
patients suffering from Malta fever clumps cultures of Bruce's 

1 Brit. Med. Journ., 1889, vol. i., p. noi. 

2 Phila. Med. Journ., 1898, vol. ii., p. 1408. 

3 British Med. Journ., 1 898, vol. ii., p. 607. 

4 Cited by Notter : Albutt's "System of Medicine," N. Y. and London, 1897, 
vol. ii., p. 472. 

5 Lancet, 1897, vol. i., p. 656. 



MEASLES. 



395 



specific micrococcus but produces no agglutination of the bacil- 
lus typhosus. The diagnostic value of this serum test in dif- 
ferentiating Malta and enteric fevers has since been corroborated 
by the reports of Aldridge, 1 Musser and Sailer, 2 Kretz, 3 Cox, 4 and 
others. A I : 50 dilution with a thirty-minute time limit appears 
to give the most satisfactory results. 

XL. MEASLES. 

The amount of fibrin is either normal or de- 
General creased, except in the event of a marked inflam- 
Features. matory complication, which may produce hyper- 
inosis. The blood plaques are decreased in num- 
ber during the febrile period. 

A peculiar bacillus has been isolated from the blood of 6 cases 
of measles, by Arsamaskoff, 5 but specificity is not unreservedly 
claimed for it. The organism in question measures about 3 fx in 
length, and is almost as broad as the Eberth bacillus ; it may de- 
velop into club forms in cultures made from the circulating blood. 
Inoculation experiments with animals gave negative results. 
Protozoa of undetermined character have been detected in the 
blood by Weber. 6 

The hemoglobin and eiythrocytes are prac- 
Hemoglobin tically unchanged in typical cases. When a de- 
and crease does occur, it is trifling, amounting at the 
Erythrocytes, most to a loss of from 250,000 to 500,000 cor- 
puscles, and of about 15 or 20 per cent, of hem- 
oglobin. The great majority of cases have counts of 5,000,000 
cells to the cubic millimeter. Qualitative changes in the erythro- 
cytes are absent. 

In the uncomplicated case of measles the num- 
Leucocytes. ber of leucocytes is either normal or subnormal. 

The latter change is very common, the decrease 
of leucocytes being most marked at the height of the fever dur- 
ing the stage of eruption, and their number again reaching nor- 
mal coincidentally with the fading of the eruption and the begin- 
ning of desquamation. The count may fall to 3,000 or 4,000 per 
cubic millimeter during the period of maximum temperature. 
Combe 7 believes that leucopenia is constant in all uncomplicated 
cases, and that the diminution in the number of cells amounts to 

1 Lancet, 1898, vol. i., p. 1394. 
2 Loc. cit. 

3 Lancet, 1898, vol. i., p. 221. 

4 Phila. Med. Jour., 1899, vol. iv., p. 491. 

5 Bolnitsch. Gaz. Botkina, 1898. Abst., Am. Year Book of Med. and Surg., 
1900, p. 317. 

6 Centralbl. f. Bakt. u. Parasit., 1897, vol. xxi., p. 286. 
7 Archiv. de med. des enf., 1899, vol. ii., p. 345. 



39 6 



GENERAL HEMATOLOGY. 



at least one-half the normal number ; he finds that the decrease 
begins during the last two days of the invasion period, and per- 
sists through the stage of exanthem. This author also found a 
striking degree of relative lymphocytosis, first developing during 
the early days of the eruption. All cases, however, do not show 
this increase in mononuclear forms, for in some the relative per- 
centages of the different varieties of leucocytes remain as in 
health. The eosinophiles are usually either diminished or else 
entirely absent during the febrile period of the disease ; occasion- 
ally they reach a high normal standard, but are not increased, as 
in scarlet fever. 

Should leucocytosis develop, it should be attributed to some 
acute inflammatory complication, such as broncho-pneumonia, 
croupous pneumonia, or severe bronchitis. 

In cases with anomalous symptoms the exist- 
Diagnosis. ence of scarlet fever may often be excluded by 
the absence of leucocytosis. Absence of increase 
' in fibrin and eosinophiles is also suggestive in ruling out this 
infection. If the diagnosis lies between measles and syphilitic 
roseola, the absence of leucocytosis points to the former. The 
initial stage of variola has been mistaken for measles, but the 
blood examination is of no aid in differentiating these two condi- 
tions, as leucocytosis is not found in small-pox at this stage of 
its development. Rotheln does not give rise to blood changes 
distinguishable from those of true measles. 

XLI. MENINGITIS. 

The condition of the hemoglobin and erythro- 
Hemoglobin cytes has not been extensively studied in this 
and disease, but so far as the data at present avail- 
Erythrocytes. able show, the only notable change to be observed 
consists in a moderate oligochromemia. This 
change, however, is inconstant, for as a rule both the number of 
corpuscles and their hemoglobin value are normal, or, perhaps, 
somewhat above normal. 

These statements, as well as those relating to the leucocytes, 
apply to the various non-tuberculous inflammations of the cerebral 
and spinal pia-arachnoid and dura mater, acute leptomeningitis and 
pachymeningitis, and epidemic cerebro-spinal meningitis. The 
blood changes associated with tuberculous meningitis are described 
elsewhere. (See " Tuberculosis.") 

Well-defined leucocytosis is found in the great 
Leucocytes, majority of instances, the counts usually ranging 
in excess of 20,000 to the cubic millimeter, tend- 
ing to attain highest figures in purulent meningitides. 



MENINGITIS. 



397 



Forty-seven cases of various non-tuberculous meningeal in- 
flammations have been observed by Williams and by Cabot, 1 in 
all but two of which the leucocytes at the first examinations 
numbered more than 10,000 to the cubic millimeter, and in the 
individual case as high as 40,000 and 50,000. The two instances 
in which the first counts failed to show leucocytosis were cases 
of epidemic cerebro-spinal meningitis, 36 of which were included 
in the entire series. 

The myth, still entertained to some extent, that tuberculous 
and non-tuberculous meningitis differ in that the former does not 
cause leucocytosis, should have been dispelled long ago. Thus, 
while Turk 2 found this sign in 32 out of 35 (or 91.4 per cent.) 
counts in non-tuberculous cases, he also noted it in four out of eight 
counts in the tuberculous form, the maximum estimate in the 
latter being 20,800 cells per cubic millimeter. Rieder 3 has re- 
ported a count of 14,400 in one case of tuberculous meningitis, 
and in another, 7,800 and 5,900 cells; leucocytosis was con- 
stant in this author's ten counts in non-tuberculous cases, 
the maximum being 29,300. Examples of this sort could be 
still further multiplied to demonstrate that leucocytosis in tuber- 
culous meningitis, although infrequent, nevertheless does occur 
at times. 

The most common differential change consists in an absolute 
and relative increase in the polynuclear neutrophils, this alteration 
tending to become most striking when the total leucocyte count 
is excessively high. In cases with a normal count, or with only 
a moderate increase, Turk observed a relatively high percentage 
of large lymphocytes and transitional forms, and he has further 
called attention to the fact that the eosinophils are either absent 
or decreased to a small fraction of one per cent, in practically 
every count, irrespective of the presence or absence of an increase 
in the total number of leucocytes. 

Between tuberculous and non-tuberculous men- 

Diagnosis. ingitis, an absence of leucocytosis strongly sug- 
gests the former, although the presence of a 
leucocytosis does not of necessity exclude it. 

Epidemic cerebro-spinal meningitis sometimes resembles such 
infections as enteric fever, typhus fever, pneumonia, and malignant 
forms of variola. In attempting these diagnoses, the presence of 
a leucocytosis almost invariably excludes typhoid, but the be- 
havior of the leucocytes is of no avail as a means of differentiating 

1 Loc. cit. 
2 Loc. cit. 
3 Loc. cit. 



398 



GENERAL HEMATOLOGY. 



pneumonia and variola ; most cases of typhus show a normal 
number of leucocytes, although a few with moderate leucocytosis 
have been reported. 

Acute meningitis cannot be distinguished by the blood' examina- 
tion from cerebral hemorrhage and abscess, since in all these condi- 
tions high counts are the rule. Cabot 1 believes that hysteria, lead 
encephalopathy, diabetic coma, sunstroke, and narcotic or alcoholic 
intoxication can be excluded by the presence of a leucocytosis, 
and that, should the diagnosis lie between meningitis on the one 
hand, and uremia and post-epileptic coma on the other, an absence 
of leucocytosis is sufficient to exclude meningitis, although its 
presence is of no diagnostic value. It is possible that bacterio- 
logical examination of the blood may furnish definite information, 
for Gwyn 2 has succeeded in repeatedly cultivating the diplococcus 
meningitidis intracellularis from the blood of a case of epidemic 
cerebro-spinal fever. Several investigators have found pneumo- 
cocci in the blood in cases of acute meningitis. 

XLII. MYXEDEMA. 

Anemia, involving chiefly the hemoglobin, is a finding in per- 
haps four- fifths of all cases, judging from Murray's 3 and Bram- 
well's 4 records of 56 patients. More rarely, high-grade anemia 
is found in this condition, as in a case examined by Le Breton, 5 in 
which the loss of hemoglobin amounted to 45, and the loss of 
erythrocytes to 66, per cent, of the normal standard, with a color 
index of 1.9 1. This author, as well as Kraepelin, 6 in several 
instances has observed a general increase in the diameter of the 
erythrocytes, and the presence of erythroblasts, but such changes 
are not ordinarily encountered. 

The leucocytes are moderately increased in a small proportion 
of patients, but never reach notably high figures ; in fully three- 
fourths of cases their number does not exceed the maximum 
normal limit. In a case published by Putnam, 7 a small number 
of myelocytes was found, but no other differential changes of 
special interest have been reported. 

A prompt increase in the hemoglobin and erythrocytes follows 
the administration of thyroid extract in appropriate doses, but, on 

1 Loc. cit. 

2 Johns Hopkins Hosp. Bull., 1899, vol. x., p. 112. 

3 "Twentieth Century Practice of Medicine," N. Y., 1 895, vol. iv. , p. 710. 

4 " Anemia," etc., London, 1899, p. 309. 

5 Bull. Soc. med. des hop. de Paris, 1895, 3 s -> v °l- x "-> P- 22 - 
6 Deut. Archiv. f. klin. Med., 1892. vol. xlix., p. 587. 

7 Am. Journ. of Med. Sc., 1893, v °l- cvi -> P- I2 5- 



NEPHRITIS. 



399 



the other hand, excessive thyroidization rapidly aggravates the 
anemia, according to Bramwell. 1 

XLIII. NEPHRITIS. 

Important contributing factors of the blood 
General changes in this condition are albuminuria, hemor- 

Features. rhage, circulatory disturbances, and the character 
of the disease with which the renal lesion may be 
associated. The fact that so many other circumstances are ca- 
pable of playing active etiological roles serves to explain the great 
dissimilarity of the blood-pictures in different nephritides, and at 
different stages of the same nephritis. 

Marked albuminuria produces in course of time a notable drain 
upon the serum proteids, and a less conspicuous deterioration of 
the corpuscles, especially affecting their volume. By this agency, 
therefore, the specific gravity of the whole blood is diminished, in 
close relationship with the extent of the drain produced. It is 
still a disputed question whether or not edema may also be held 
responsible for this change. In cases with hematuria as a promi- 
nent symptom, the familiar picture of a post-hemorrhagic anemia 
may be encountered, and in kidney inflammations which accom- 
pany an acute infectious process, the effects of the latter upon 
the blood are to be remembered. 

The amount of fibrin may be found to be increased, especially 
in contracted kidney ; the rate of coagulation is, so far as has been 
determined, exceedingly inconstant. 

Von Jaksch, 2 von Limbeck, 3 and others have drawn attention 
to diminished alkalinity of the blood as a sign anticipating and ac- 
companying uremic attacks. 

Bacteriological examination of the blood proves negative, except 
in the terminal stages of nephritis, when evidences of a general 
circulatory invasion by micro-organisms may sometimes be de- 
tected. Thus, excluding this factor, James and Tuttle 4 failed to 
demonstrate pathogenic bacteria in the blood of 6 successive 
chronic cases ; while, on the other hand, White 5 obtained growths 
of streptococci in 3 consecutive cases of chronic parenchymatous 
nephritis, on the second, third, and fourth days before death, 
respectively, these positive findings being attributed to terminal 
septicemia. 

1 Loc. cit. 

2 Zeitschr. f. klin. Med., 1887, vol. xiii., p. 350. 

3 Loc. cit. 

4 Loc. cit. 

5 Loc. cit. 



400 



GENERAL HEMATOLOGY. 



In acute parenchymatous nephritis the hemo- 
Hemoglobin globin and erythrocyte values may remain per- 
and fectly normal, or, as is more usual, a moderate 
Erythrocytes, secondary anemia develops, of which a greatly 
disproportionate oligochromemia is a notable fea- 
ture. The grade of the anemia is highest in cases with marked 
albuminuria and hematuria, but only exceptionally is a loss of 
more than 2,000,000 cells noted. Laache 1 estimates the aver- 
age loss in hemoglobin at 26 per cent, and in erythrocytes at 19 
per cent., and considers that the decrease is much more severe 
in acute than in chronic cases. Hayem 2 is authority for the 
statement that striking anemia develops only in cases with 
hematuria. 

In chronic parenchymatous nephritis most observers state that 
moderate hemoglobin and erythrocyte decreases are the most 
notable findings, but some report severe anemia the grade of 
which is likely to be most intense in cases with marked, persistent 
albuminuria, and with associated lesions of other organs. Sor- 
ensen 3 found that the count of erythrocytes in this form of renal 
disease averaged 4,700,000 to the cubic millimeter, but in the 
writer's experience a much more pronounced loss has been ob- 
served — an average hemoglobin percentage of 57.1, and an aver- 
age erythrocyte count of 3,971,206 per cubic millimeter, in a 
series of 1 5 cases. A synopsis of the examinations in these 
cases shows the following data : — Hemoglobin percentage : 80— 
90 in 1 ; 70-80 in 2 ; 60-70 in 4 ; 50-60 in 3 ; 40-50 in 2 ; 
and 30-40 in 3. Erythrocyte counts : above 5,000,000 in 2 ; 
4,000,000-5,000,000 in 4 ; 3,000,000-4,000,000 in 8; 2,000,- 
000-300,000 in 1. The maximum hemoglobin estimate in this 
series was 82, and the minimum 30, per cent.; the maximum 
number of erythrocytes per cubic millimeter was 5,520,000, 
and the minimum 2,270,000. The average color index was 
0.71. 

Polycythemia, masking the real condition of the blood, is not 
at all uncommon ; it may arise from some such cause as cyano- 
sis, or the sudden development of an extensive edema. Every 
clinician must have been repeatedly struck by the evident dis- 
crepancy between the blood report and the pinched, waxy, ne- 
phritic facies. 

In chronic interstitial nephritis, so long as circulatory disturb- 
ances do not exist, the condition of the blood remains practically 

^'Die Anaemie," Christiania, 1883. 
2 Loc. cit. 

3 Cited by Grawitz, loc. cit. 



NEPHRITIS. 



40I 



normal, but as soon as the compensatory hypertrophy of the left 
ventricle becomes inadequate, the blood changes identified with 
uncompensated valvular heart disease develop, and various de- 
grees of apparent anemia and polycythemia become evident from 
time to time. These factors, the importance of which is insisted 
upon by Grawitz, 1 no doubt serve to explain most of the blood 
changes found in sclerotic kidney, but it seems obvious that 
neither the malnutrition of the patient nor the considerable hem- 
orrhages from which he often suffers should be disregarded as 
possible causes of blood deterioration. 

All the structural changes affecting the erythrocytes in sec- 
ondary anemia may occur in association with any of the preced- 
ing varieties of nephritis, should the accompanying anemia be 
sufficiently striking. 

In acute parenchymatous nephritis, leucocytosis 
Leucocytes, may develop in the early stages of the disease, 
and persist for some time after convalescence is 
established. Cabot, 2 who attributes the increase to the effects 
of hemorrhage and of uremia, found it present in 6 of his 13 
cases, the maximum count being 22,000 per cubic millimeter. 
In three cases, in which these two factors were excluded, the 
writer found that the number of leucocytes was 6,400, 3,200, and 
8,700, respectively. 

In the 1 5 cases of chronic parenchymatous nephritis, above 
mentioned, the number of leucocytes averaged 8,626 per cubic 
millimeter, the maximum being 16,000, and the minimum 4,000. 
Four of the counts were in excess of 10,000 ; 9 from 5,000- 
10,000; and 2 below 5,000. 

Chronic interstitial nephritis does not of itself influence the 
number of leucocytes. 

Uremia may or may not be associated with leucocytosis ; 
the change is to be noted in the majority of nephritides in 
which this complication supervenes, but it is by no means con- 
stant. 

In all the above forms of kidney inflammation, the leucocy- 
tosis, if present, is of the polynuclear neutrophile type. 

The blood count is of no diagnostic value in 
Diagnosis, nephritis, nor can it always be relied upon to in- 
dicate accurately the richness of the blood in cel- 
lular elements, owing to the frequent prevalence of factors which 
cause dilution and inspissation. 

1 Loc. cit. 
2Loc. cit. 



26 



GENERAL HEMATOLOGY. 



XLIV. NERVOUS AND MENTAL DISEASES. 

In a single case of febrile multiple neuritis 
Neuritis. Cabot 1 found a moderate degree of secondary 
Beri-beri. anemia, with leucocytosis, the counts, 8 in num- 

Neuralgia. ber, ranging from 16,000 to 28,700 per cubic 
Brain Tumor, millimeter, and the latter figure being reached 
during the post-febrile period of the attack. This 
author also noted a moderate anemia and leucocytosis in 4 of 6 
cases of alcoholic neuritis, but found the number of leucocytes 
normal in 25 cases of plumbic neuritis. 

Beri-beri, according to Spencer, 2 is usually associated with a 
well-defined secondary anemia, in some instances characterized 
by striking qualitative changes affecting the size and shape of the 
erythrocytes. The leucocytes, both in number and in the rela- 
tive percentages of their different varieties, remain normal, ex- 
cept in the acute stages of the infection, when an increase in the 
eosinophiles may develop. Fajardo 3 has detected a spore -form- 
ing, pigment-producing hematozoon, and Rost 4 a diplobacillus 
in the blood of beri-beri patients, each of which organisms has 
been regarded by their respective discoverer as the specific cause 
of the disease. Other investigators, notably Affleck, 5 have ob- 
tained negative results from bacteriological blood examinations. 

Neuralgia, whatever its seat, is capable of exciting neither 
anemia nor leucocytosis. 

The blood in brain tumor usually deviates in no manner from 
the normal, although rarely a moderate leucocytosis has been 
observed. This is a distinct contrast to cerebral abscess and hem- 
orrhage, in both of which conditions leucocytosis is the general 
rule. The condition of the blood in meningitis has already 
been described. (See page 396.) 

Neurasthenia, hypochondriasis, and hysteria, 

Functional while they do not primarily serve as factors of 

Neuroses. blood deterioration, are in some instances associ- 
ated with other conditions which lead to moderate 
secondary anemia, usually involving chiefly the hemoglobin, and 
but rarely causing any appreciable diminution in the number of 
erythrocytes. But, as a rule, functional neurotics have normal 
blood, in spite of their anemic appearance. Luxemberg, 6 in a 

1 Loc. cit. 

2 Lancet, 1897, vol. i., p. 32. 

3 Centralbl. f. Bakt. u. Parasit., 1900, vol. xxvii., p. 249. 

4 Lancet, 1901, vol. i., p. 66. 

5 Edinburgh Med. Journ., 1900, vol. viii., p. 33. 

6 Centralbl. f. inn. Med.. 1899, vol. xx., p. 533. 



NERVOUS AND MENTAL DISEASES. 



403 



study of 40 cases of hysteria and neurasthenia, found that poly- 
cythemia was common, having repeatedly noted erythrocyte 
counts as high as 6,000,000, and even in one instance 7,300,000 
per cubic millimeter ; he attributes this to vasomotor changes, 
possibly due in large part to the effect of the examination itself. 
Reinert, 1 examining 74 cases of these two forms of neurosis, 
found a moderate hemoglobin diminution in many cases of hys- 
teria, but normal blood in neurasthenia. In sexual neurasthe- 
nia, however, anemia is not at all uncommon, in the writer's 
experience. MacPhail 2 speaks of the marked anemia usually 
found in insane masturbators, and every clinician who has made 
many routine blood counts must have been struck with the fact 
that the pallid, pasty face of the confirmed masturbator but sel- 
dom falsely reflects the state of the sufferer's blood. 

The functional neuroses are not accompanied by leucocytosis, 
but, on the other hand, in many cases a decided leucopenia is 
present. In all a relatively increased proportion of lympho- 
cytes may frequently be observed, while in hysteria the num- 
ber of eosinophiles may be relatively in excess of the normal 
standard. 

MacPhail, 3 in a prize-essay submitted to the 
General Medico-Psychological Association of Great 
Paresis. Britain, in 1884, concludes that these mental dis- 
Dementia. eases are in many instances closely associated 
Melancholia, with a more or less decided anemia, although in 
Mania. no sense can blood deterioration be regarded as a 
factor of insanity. In general paresis this observer 
found subnormal hemoglobin values, averaging about 67 per cent., 
on the patients' first admission to the hospital, but later, as the 
patient profited by the improved hygienic environment, this value 
rose, only again to fall to an average of 52 per cent., in the terminal 
stages of the affection. The oligocythemia steadily increased as 
the disease progressed, and occasionally reached in the individual 
case a minimum count of between 3,000,000 and 4,000,000 eryth- 
rocytes per cubic millimeter ; it was more striking during the active 
and completely paretic stages than during the intervening periods 
of quiescence. A well-defined leucocytosis was constant, and 
many of the counts made shortly before death reached high figures. 
Capps, 4 in a study of 19 cases, found that the hemoglobin averaged 
85 per cent., and the erythrocytes 4,789,900 per cubic millimeter 

1 Munch, med. Woch., 1895, vol. xlii., p. 305. 

2 Journ. of Mental Sc., 1884, vol. xxx., pp. 378 and 488. 

3 Loc. cit. 

4 Am. Journ. of Med. Sc., 1896, vol. cxi., p. 650. 



404 



GENERAL HEMATOLOGY. 



— figures which may be compared with Smyth's average estimates 1 
in 40 cases : hemoglobin, 68.7 per cent., and erythrocytes, 4,- 
700,000. Capps states that the majority of cases show a moder- 
ate leucocytosis, averaging an increase of 22 per cent, in excess of 
the normal standard, but that in the incipient stages of the disease 
the number of leucocytes usually is not increased. An average 
count of 8,800 was noted by Somers, 2 in 5 cases. Relatively high 
percentages of polynuclear neutrophiles, with a diminution in the 
small lymphocytes, are common differential changes, while the 
relative numbers of large lymphocytes and eosinophiles may be 
higher than normal. Convulsions and apoplectiform attacks tend 
to produce blood concentration, and therefore temporarily in- 
crease the hemoglobin and erythrocyte values. During and fol- 
lowing such seizures, an abrupt rise in the leucocyte curve, 
characterized by a striking absolute and relative gain in the large 
lymphocytes, and, rarely, by the appearance of myelocytes, was 
observed by Capps, who has also described a small mononuclear 
neutrophilic leucocyte, resembling a dwarf myelocyte, as peculiar 
to the condition in question. (See page 171.) Burrows 3 believes 
that the leucocytosis associated with convulsions, not only in 
general paralysis, but in other conditions, bears a definite relation, 
to the severity of the fit, and that the increase is in part the result 
of the muscular contractions attending the convulsion, and in part 
represents an actual pathological leucocytosis. Acute delirium 
from any cause also provokes leucocytosis. 

In dementia, according to Smyth, 4 both the hemoglobin and 
erythrocytes are decidedly lower than in the preceding condition, 
his averages for this disease being 53.7 per cent, of hemoglobin, 
and a count of 4,070,000 erythrocytes, in a series of 12 cases. 
In 10 cases of melancholia he found that the hemoglobin averaged 
69.7 per cent, and the erythrocytes 4,684,000, while Steele, 5 in 
35 cases of this disease, estimated the average hemoglobin value 
at 75 per cent, and the average erythrocyte count at 3,000,000. 
In acute mania anemia of the so-called " chlorotic " type usually 
may be observed ; this blood change becomes aggravated by each 
acute maniacal outbreak, but after recovery from these attacks 
the deficiency is rapidly restored. Somers' 6 leucocyte counts in 
19 dements averaged 10,743, in 19 melancholies 7,947, and in 
19 maniacs 8,3 1 5. 

1 Journ. of Mental Sc., 1890, vol. xxxvi., p. 504. 

2 Bull. N. Y. State Hosp., 1896. 

3 Am. Journ. of Med. Sc., 1899, vol. cxvii., p. 503. 

4 Loc. cit. 

3 Am. Journ. of Insanity, 1892, vol. xlix., p. 604. 
6 Loc. cit. 



OBESITY. 



405 



In epilepsy a moderate anemia appears to be the 
Epilepsy. general rule. Smyth's studies 1 of 50 cases show 
Chorea. an average of 62.8 per cent, of hemoglobin, and 
Tetany. 4,520,000 erythrocytes per cubic millimeter. 

MacPhail 1 asserts that prolonged attacks of ex- 
citement notably increase the anemia, but . that the habitual ad- 
ministration of bromides seems in no manner to produce deleterious 
effects upon the blood. Furthermore, this author observed that 
a close relationship can be distinguished between the patient's gain 
in weight, the decrease in the anemia, and the mental improve- 
ment, and that in patients who recovered, the regeneration of the 
blood became practically complete. Leucocytosis does not occur 
in epilepsy, except as the result of a convulsion. Kuhlmann, 2 
for example, found the leucocytes in excess of normal but once in 
a study of 16 cases. 

In chorea slight anemia, usually of the " chlorotic " type, occurs 
with frequency but not with constancy, for many cases habitually 
show normal hemoglobin and erythrocyte values. It seems 
scarcely necessary to remark that the belief once entertained, that 
blood deterioration was a causal factor of this disease, is obviously 
erroneous. Burr, 3 in a study of the hemoglobin and erythrocytes 
in 36 cases, concludes that a moderate diminution in both of these 
elements is the general finding, and that a high grade of anemia 
occurs only as the result of some complication. The oligocy- 
themia usually does not exceed a loss of more than 1,000,000 
cells per cubic millimeter, in uncomplicated cases. The leuco- 
cytes are not increased, but differential counts may detect a rela- 
tively large percentage of eosinophiles, according to the reports 
of Zappert, 4 and others. Tetany is not of itself a cause of blood 
impoverishment. 

XLV. OBESITY. 

From Kisch's studies 5 it is evident that the hemoglobin values 
are notably high in most corpulent individuals, and in some ex- 
cessively increased. In 79 of 100 cases of obesity examined by 
this author, the hemoglobin percentage exceeded 100, while in 
the remaining 21 moderate oligochromemia was found. The 
maximum reading in this series was 120 and the minimum 55 
per cent. Actual anemia, however, is not incompatible with this 

1 Loc. cit. 

2 Bull. N. Y. State Hosp., 1897. 

3 University Med. Mag., 1896, vol. ix., p. 188. 
4 Zeitschr. f, klin. Med., 1893, vol. xxiii., p. 227. 
5 Ibid., 1887, vol. xii., p. 357. 



406 



GENERAL HEMATOLOGY. 



class of patients, as demonstrated by Leichtenstern, 1 and by 
Oertel. 2 The latter also maintains that in some instances true 
plethora exists, and furthermore professes to recognize two dis- 
forms of obesity, an anemic and a plethoric. Data regarding the 
leucocytes in this condition are wanting. 

XLVL OSTEOMALACIA. 

The hemoglobin and erythrocytes do not exhibit any marked 
deviations, being in most instances normal, or but moderately di- 
minished. The anemia, when present, tends to conform to the 
so-called " chlorotic type," being characterized by a hemoglobin 
loss relatively exceeding that of the corpuscles. 

The leucocytes also remain approximately normal in number, 
slight fluctuations above and below this standard being the only 
numerical change thus far noted. Relative lymphocytosis has 
been found by Ritchie, 3 and by Tschistowitch, 4 while Neusser 5 
and others have observed in many cases a moderate increase in 
the eosinophiles, and the presence of small numbers of myelo- 
cytes. None of these differential changes, however, are to be 
considered constant in this condition. According to von Lim- 
beck, 6 the alkalinity of the blood remains practically unal- 
tered, although von Jaksch 7 formerly maintained that it was 
considerably diminished. 

XLVII. PERICARDIAL EFFUSION. 

The hemoglobin and erythrocytes remain normal, or, if anemia 
is found, it may be referred to other coexisting conditions. 

Leucocytosis of the polynuclear neutrophile type is practically 
a constant change in the non-tuberculous forms, but in tuber- 
culous pericarditis the leucocytes apparently do not increase. 
From a diagnostic viewpoint, the presence of a leucocytosis is of 
real value in excluding the latter condition, as well as cardiac 
dilatation ; this sign is also strong evidence against the existence 
of a serous pleural effusio?i, which, if left-sided, may simulate 
pericarditis. 

1 " Untersuch. u. d. Hg-Gehalt d. Blutes," Leipzig, 1878. 

2 " Allgem. Ther. d. Kreislaufsstor.," Leipzig, 1884. Also, Deut. Archiv. f. 
klin. Med., 1892, vol. i., p. 293. 

3 Edinburgh Med. Journ., 1896, vol. xlii., p. 208. 

4 Berl. klin. Woch., 1893, vol. xxx., p. 919. 
5 Wien. klin. Woch., 1892, vol. v., p. 41. 
6 Loc. cit. 

T Zeitschr. f. klin. Med., 1S87, vol. xiii. , p. 350. 



PERITONITIS. 



407 



XL VIII. PERITONITIS. 

Anemia is frequently found, the degree of 
Hemoglobin which largely depends upon the character and 
and the chronicity of the inflammation. In general 
Erythrocytes, purulent peritonitis, especially in cases of com- 
paratively long standing, the hemoglobin and 
erythrocyte diminution may be excessive — to between 20 and 30 
per cent, for the former, and to between 2,000,000 and 3,000,000 
per cubic millimeter for the latter. With such an anemia as this 
the erythrocyte loss is commonly very disproportionate to that 
of the hemoglobin, so that high color indices rule ; for example, 
in 3 of the cases summarized below, the indices were 1.12, 1.01, 
and 1. 00, respectively. The several qualitative changes accom- 
panying any severe secondary anemia are also commonly to be 
observed. Serous peritonitis has but little effect in provoking 
a cellular decrease, although it usually causes a slight but 
definite oligochromemia, so that in such cases the color indices 
are moderately subnormal. On the average, it may be stated 
that peritonitis causes a loss of about 40 per cent, of hemoglobin, 
and of 20 per cent, of erythrocytes. 

The following summary of 16 cases, most of which were ex- 
amined at the German Hospital, shows the grade of anemia pre- 
vailing in this disease : 

Hemoglobin Number of Erythrocytes Number of 

Percentage. Cases. per cb. mm. Cases. 

From 80-90 1 Above 5,000,000 3 

" 70-80 5 From 4,000,000-5,000,000 5 

" 60-70 4 " 3,000,000-4,000,000 6 

" 50-60 1 " 2,000,000-3,000,000 2 

" 40-5° 3 
" 30-40 1 
" 20-30 1 

Average: 62.1 per cent. Average: 3,970,000 per cb. mm. 

Maximum: 82.0 " " Maximum: 5,670,000 '? " " 

Minimum: 28.0 " " Minimum: 2,150,000 " " " 

The color index for this series averaged 0.78. 

Provided that the patient's resisting powers react 
Leucocytes, normally, septic peritonitis constantly causes a typ- 
ical leucocytosis, of the polynuclear neutrophile 
variety. It cannot be stated with certainty that the increase is 
greater in purulent than in serous inflammations, for any variety 
of peritonitis, except the tuberculous, may provoke a striking 
leucocytosis. As already remarked in the discussion of appen- 
dicitis, extension of the process is heralded by an abrupt rise in 



408 



GENERAL HEMATOLOGY. 



the leucocyte curve. As in other infections, leucocytosis may be 
absent, or leucopenia may exist, in cases of a profound, crippling 
character. The number of leucocytes in the preceding 16 cases 
ranged as follows : 

Leucocytes per cb. mm^ No. of Cases. 

Above 45,000 I 

From 35,000-45,000 1 

" 25,000-35,000 1 

" 20,000-25,000 1 

" 15,000-20,000 4 

il 10,000—15,000 6 

" 5,000-10,000 1 

Below 5,000 1 

Average : 18,875 P er °h« mm. 

Maximum: 46,000 " " " 

Minimum: 4,400 " " " 

The presence of leucocytosis is sufficient evi- 
Diagnosis. dence for the exclusion of tuberculous peritonitis, 
so-called hysterical peritonitis, and rheumatism of 
the abdominal muscles. This sign, however, cannot safely be 
employed to differentiate between peritonitis and acute enteritis, 
certain forms of intestinal obstruction, and rupture of a tubal 
pregnancy or of an abdominal aneurism, all of which may cause 
more or less leucocyte increase. 

Cabot 1 regards the association of marked leucocytosis with 
hyperinosis as strongly in favor of a peritoneal inflammation 
rather than of such conditions as non-malignant bowel obstruction, 
malignant disease, hysteria, and phantom tumors. 

XLIX. PERTUSSIS. 

In so far as can be learned from the scanty literature at pres- 
ent available, the hemoglobin and erythrocyte values remain normal 
in this disease. Pronounced increase in the number of leucocytes, 
more marked than is found in any other non-febrile lesion of the 
respiratory tract, is a characteristic finding in whooping-cough. 
Frolich and Meunier, 2 who originally determined this fact, found 
in 30 cases an average of 27,800 leucocytes per cubic millimeter, 
the individual counts ranging from a minimum of 1 5,500 to a max- 
imum of 51,150. De Amicis and Pacchioni 3 have corroborated 
this observation, although they consider that the increase is some- 
what less, having found an average count of 17,943 for their cases. 

1 Loc. cit. 

2 Compt. rend. Soc. biol., Paris, 1898, ios., vol. v., p. 103. 
3 Clinica Medica, 1899, vol. iv., p. 103. 



PLEURISY. 



4O9 



The leucocytosis develops during the early stages of the disease, 
before the cough begins, and usually persists for some time after 
convalescence is established. As a general rule, it may be stated 
that the younger the child, the more notable the increase. 
Lymphocytosis, with a consequent diminution in the polynuclear 
neutrophils and eosinophils, is a constant and conspicuous dif- 
ferential change. This lymphocytosis, according to Ehrlich, 1 
is to be attributed to the stimulation and swelling of the tracheo- 
bronchial lymphatic glands. 

The fact that a marked leucocyte increase occurs in the early 
catarrhal stages of the disease, antedating the development of the 
typical cough, may prove of diagnostic significance. 

L. PLEURISY. 

Serous Pleurisy. 

In acute cases it is customary to find normal 
Hemoglobin hemoglobin and erythrocyte values, or, at the 
and most, simply a moderate oligochromemia ; in 
Erythrocytes, those of longer standing, with decided debility of 
the patient, anemia, sometimes of a considerable 
degree, is not an uncommon finding. Thus, in an instance of this 
sort the writer found but 38 per cent, of hemoglobin and 3,300,- 
000 erythrocytes per cubic millimeter, together with the corpus- 
cular degenerative changes to be expected in an anemia of this 
intensity. It is to be remembered that a rapidly developing 
pleural effusion may so concentrate the blood as to cause a tem- 
porary polycythemia, disguising the actual quantitative changes. 

Absence of leucocytosis is the general rule, 
Leucocytes, probably for the reason that almost all serous 
pleurisies are of tuberculous origin. Exception- 
ally a moderate, intermittent increase is found, chiefly affecting 
the polynuclear neutrophiles, and due possibly to the influence of 
some intercurrent process, such as a secondary pneumococcus in- 
fection. A notable increase in the eosinophiles may often be found 
in hemorrhagic pleural effusions. In children a leucocytosis is 
sometimes found, apparently independent of secondaiy infections. 
It is quite evident that the behavior of the leucocytes can not be 
used as a means of differentiating tuberculous from non-tubercu- 
lous effusions. 

Morse, 2 in a study of 224 examinations made in 20 cases, 
comes to the conclusion that there is no definite relation between 
the leucocyte count and the duration of the disease, the degree 

1 Loc. cit. 

2 Am. Journ. of Med. Sc., 1900, vol. cxx., p. 658. 



GENERAL HEMATOLOGY. 



of pyrexia, the amount of the effusion, and its increase and dim- 
inution. Neither could he determine that the contamination of 
the fluid by blood and by microscopical pus produced the 
slightest effect upon the number of cells. In Morse's counts the 
number of leucocytes exceeded 10,000 to the cubic millimeter in 
5.8 per cent., while in Cabot's 99 cases 1 this figure was exceeded 
in 14. 1 per cent., the average count for the latter being 6,130. 

Purulent Pleurisy. 

The changes in the hemoglobin and erythro- 
Hemoglobin cytes do not differ conspicuously from those pre- 
and vailing in primary serous pleurisy, although evi- 
Erythrocytes. dences of a decided anemia are to be observed 
somewhat more frequently. 
In 8 of the writer's 10 cases of empyema the hemoglobin loss 
exceeded 50 per cent, of the normal, 38 per cent, being the min- 
imum, 73 per cent, the maximum, and 46 per cent, the average, 
estimate. The erythrocytes were below 2,000,000 to the cubic 
millimeter in 2 instances, averaging 3,500,000, with 1,540,000 as 
the minimum and 4,600,000 as the maximum, counts. 

Leucocytosis, ordinarily of a high grade, accom- 
Leucocytes. panies the great majority of cases, the increase 
involving mainly the polymiclear neutrophile cells 
at the expense of the lymphocytes. It is more usual to find 
the count above than below 20,000 to the cubic millimeter, 
and in an exceptional instance it may even exceed 50,000. As- 
piration of the pus is followed by a decline, and its reaccumula- 
tion by a rise, in the leucocyte curve. The extent of the primary 
purulent accumulation cannot be gauged with any accuracy by 
the degree of the leucocyte increase. 

The following counts in a case of empyema examined at the 
German Hospital, will serve to illustrate the high leucocytosis 
sometimes seen in this condition : 



Date. 


Hemoglobin Per- 
centage. 


Erythrocytes per 
cb. mm. 


Leucocytes per 
cb. mm. 


I -I 6-00 


84 


4,460,000 


23 , 200 


I-17-OO 


88 
82 


5,38o,OCO 


42,400 


I-18-OO 


4,320,000 


45,000 


I- I 9-OO 


82 


4,430,000 


40,800 


I-20-00 


83 


4,383,000 


23,320 


I-2I-00 


82 


4,410,000 


44,300 


I-22-OO 


81 


4,330,000 


40,600 


I-23-OO 


7i 


3,985,000 


37,300 


I-24-OO 


67 


4,360,000 


53,500 


I-26-OO 


83 


4,240,000 


47,IOO 


I-27-OO 


7i 


3,480,000 


48, IOO 



Loc. cit. 



PNEUMONIA. 



411 



In 9 out of the other 10 cases above noted, a leucocyte in- 
crease was found, the counts for the 10 averaging 17,180 and 
ranging from 8,600 to 31,600 per cubic millimeter. 

The presence of a well-developed leucocytosis 

Diagnosis, points to pneumonia or empyema, rather than to 
simple serous pleurisy, but it does not differentiate 
between these first two conditions. On the other hand, an ab- 
sence of leucocytosis does not surely exclude pneumonia and 
empyema, although it is extremely suggestive that neither exists. 
Malignant neoplasms of the lungs and pleura also cause a decided 
leucocyte increase. 

LI. PNEUMONIA. 

In the case of average severity, coagulation is 
General exceedingly rapid, and the amount of fibrin 
Features. greatly increased, the network being dense, coarse, 
and formed with great rapidity. The hyperinosis 
tends to persist for some time after the disappearance of the 
pyrexia and the signs of lung involvement. In severe infections, 
occurring in individuals of good resisting powers, the change is 
especially striking, but in fatal cases, overwhelmed by the disease, 
a fibrin increase is not observed. High temperature and exten- 
sive infiltration of the lungs are associated with marked hyperi- 
nosis. In children the specific gravity of the blood is usually 
high during the febrile period, falling to normal as resolution 
takes place ; in cases with marked cyanosis the concentration of 
the blood also raises its density. Attempts to apply the serum test 
in this disease have thus far been failures, the reports of those who 
have experimented with this reaction having shown that the pneu- 
mococci are either wholly unaffected by the serum of pneumonia 
patients, or at the most, agglutinate very slowly and atypically. 

The diplococcus pneumonia is present in the 
Bacteriology, circulating blood in only a small proportion of 
cases, for the bacterial products, and not the or- 
ganisms themselves, gain access to the general circulation, as a 
general rule. Positive bacteriological findings are commonest in 
those cases complicated by a secondary pneumococcus infection, 
and are always to be regarded as a grave prognostic sign. 

Franklin W. White, 1 in 19 carefully studied cases of pneumonia, 
obtained positive results in 3 patients, all of whom died ; of the 16 
negative cases, 7 proved fatal. Sittmann 2 found the pneumo- 
coccus in 6 out of 16 cases examined by him, in 4 cases by cul- 

1 Journ. of Exper. Med., 1899, vol. iv., p. 425. 
2 Deut. Archiv. f. klin. Med., 1894, vol. liii., p. 323. 



412 



GENERAL HEMATOLOGY. 



tural methods, and in 2 in stained cover-slip preparations of the 
blood ; of these 6 positive cases, 4 died, and of the 10 negative 
cases, but a single one ended fatally. Kohn 1 examined 32 cases, 
obtaining positive results in 9, of which number 7 cases were 
fatal, while the other 2 finally recovered after a grave infection ; 
of this author's 23 negative cases, recovery took place in 8. 
Pieraccini 2 found the pneumococcus in the blood in 1 1 out of 28 
cases, while Silvestrini and Baduel 3 claim to have cultured this 
organism in 15 out of 16 pneumonia patients whom they exam- 
ined. These Italian observers found that the number of bacteria 
in the blood usually, but not invariably, stood in relation to the 
gravity of the infection. On the other hand, James and Tuttle, 4 
in their studies of 12 cases, 2 of which were fatal, failed in every 
instance to obtain positive findings. 

From a study of the above statistics, together with those of 
other investigators reporting smaller series of cases, it is to be 
concluded that the presence of the pneumococcus in the blood is 
exceedingly inconstant, and that positive findings are usually ob- 
tained only in grave or fatal cases. Eight of every ten cases with 
pneumococcus bacteriemia end fatally. Negative results from 
blood culturing, however, cannot be considered of definite prog- 
nostic value in favor of the patient's recovery. 

During the active stages of the fever the hemo- 
Hemoglobin globin and erythrocytes are either normal or 
and very slightly diminished. But polycythemia also 
Erythrocytes, may occur, as the result of the fever's influence 
in causing contraction of the peripheral vessels, 
or from cyanosis. During the post-febrile period moderately 
low counts are usually found, being due possibly to the hemo- 
cytolytic effects of the fever, and to a dilution of the blood caused 
by the decreased arterial tension which occurs at this stage of 
the illness. The loss, in the writer's experience, amounts in the 
average case to about 20 per cent, of the normal number of cells, 
with a somewhat greater hemoglobin decrease — approximately 3 5 
per cent. In 1 3 cases, examined after the seventh day of the dis- 
ease, the hemoglobin averaged 66 per cent., being as low as 40 
and as high as 1 10 per cent, in the individual case ; the average 
erythrocyte count was 3,988,450 per cubic millimeter, ranging 
from 3,200,000 to 5,500,000. Poikilocytosis, and other struc- 
tural changes in the cells are to be noted only in severe cases. 

1 Deut. med. Woch., 1897, vol. xxiii., p. 136. 

2 Centralbl. f. allg. Path. u. pathol. Anat., 1900, vol. xi., p. 460. 

3 Ibid., p. 447. 

4 Loc. cit. 



PNEUMONIA. 



413 



In pneumonia, as in other acute infections, the 
Leucocytes, severity of the infective process and the intensity 
of the reaction on the part of the organism are 
the factors which determine the behavior of the leucocytes. In 
the great majority of cases a well-marked leucocytosis develops 
at or soon after the time of the initial chill, and persists until 
shortly after the temperature has fallen to normal. 

A high leucocytosis indicates a severe infection in an indi- 
vidual of strong resisting powers. A moderate increase indicates 
either a slight infection coupled with good resistance, or an in- 
tense infection with an inadequate reaction. Little or no leuco- 
cyte increase also suggests one of two diametrically opposite con- 
ditions : either an infection too trivial to excite reaction, or one so 
severe as to overpower the organism, stifling reaction. Ewing 1 
has found that, as a rule, the increase is greater in cases with 
extensive lung involvement than in those with limited lesions, but 
this parallelism between the degree of leucocytosis and the extent 
of the pneumonic process is approximate, and does not always 
hold good. In a general sense, it applies only to cases which 
react well toward the disease. There is no relationship between 
the degree of increase and the degree of fever during the active 
stages of pneumonia. 

In the average well-marked case the number of leucocytes 
usually ranges between 20,000 and 30,000 per cubic millimeter, 
the latter figure being only rarely exceeded, as, for example, in 
severe sthenic cases, in which the count may rise to 40,000 or 
50,000. Summing up a total of 470 cases reported by various 
observers, we find that the average " first count" of the leuco- 
cytes, during the febrile stage of the disease, was 22,693, this fig- 
ure applying to all cases, both with and without leucocytosis. 
Between 5 and 10 per cent, of all cases fail to develop an increase, 
and of these over 95 per cent, end fatally, so that from this fact, 
an absence of leucocytosis must be regarded as of distinctly un- 
favorable prognosis, except in those cases in which the type of 
the infection is obviously mild. The occurrence of a high leuco- 
cytosis is of no definite prognostic value, since it indicates simply 
a marked infection and good resisting powers. 

The following table shows the range of the leucocytes in 27 
hospital cases of pneumonia : 

Above 45,000 in 2 cases. 

From 25,000-30,000 " 1 -case. 
" 20,000-25,000 " 8 cases. 
" 15,000-20,000 " 4 " 

1 N. Y. Med. Journ., 1893, v °l- l v »i-> P- 7 I 5- 



414 



GENERAL HEMATOLOGY. 



From 10,000-15,000 in 4 cases. 
" 5,000-10,000 " 7 " 
Below 5,000 " 1 case. 

Highest : 53,500 per cb. mm. 
Lowest : 4,000 " " " 
Average: 17,303 " " " 

In cases terminating by crisis, the leucocytes begin to diminish 
either a short time before or after the temperature commences to 
decline, the normal number being reached, in most cases, within 
twenty-four or forty-eight hours after crisis occurs, although in a 
small proportion of cases the decrease is much slower, the count 
sometimes not reaching normal until a week after the tempera- 
ture has dropped. False crises, although they may cause a strik- 
ing drop in the temperature, do not cause a decline of the leu- 
cocyte curve. 

In cases ending by lysis, the decrease in the number of leuco- 
cytes and the decline in the temperature begin simultaneously, 
but the latter reaches normal much more rapidly than the former ; 
the leucocyte decrease progresses more gradually than in the 
cases ending by crisis, and the normal count is often not reached 
until a week or ten days after the temperature has fallen to the 
normal figure. At the beginning of lysis a correspondence may 
be distinguished between the diurnal fluctuations of the temper- 
ature and leucocyte curves, although no such relation is apparent 
during the febrile period of the disease. 

It is an interesting fact that in about half of all cases, whether 
ending by crisis or by lysis, the maximum count of leucocytes is 
attained during the period of temperature decline. 

Von Jaksch's 1 idea of injecting substances to cause leuco- 
cytosis in pneumonia where this phenomenon was absent, hoping 
thereby to benefit the patient, has not been attended by the favor- 
able results which he anticipated. Leucocytosis is as promptly 
induced in the pneumonic as in the healthy individual, by the 
injection of nuclein, for example, but without beneficial effect 
upon the patient's condition, a fact which must be regarded as 
evidently signifying that an absence of leucocytosis in fatal cases 
is not the cause of death, as Billings 2 remarks. 

Hare 3 has drawn attention to the fact that while leucocytosis 
is checked by antipyretics, it is not arrested by cold sponging, an 
observation which prompts Cabot 4 to declare in favor of the latter 
method of reducing temperature in pneumonia. 

1 Cited by Cabot, loc. cit. 

2 Johns Hopkins Hosp. Bull., 1894, vol. v., p. 1 1 2. 

3 Therapeutic Gaz., 1898, vol. xii., p. 153. 

4 Loc. cit. 



PNEUMONIA. 



415 



The leucocytosis of pneumonia is of the typical variety, that is, 
it is due to a large absolute and relative increase in the poly- 
nuclear neutrophils, with a consequent relative decrease in lym- 
phocytes. The proportion of eosinophiles is much reduced, and 
frequently these cells are entirely wanting. This is regarded as 
an unfavorable sign by Becker, 1 who states that he has never 
found eosinophiles in fatal cases. With the decline of the tem- 
perature and the fading away of the leucocytosis, the percentage 
of polymorphous cells rapidly falls to normal or subnormal, and 
the lymphocytes and eosinophiles increase until they regain their 
normal percentages. The latter cells usually begin to reappear 
in the circulation a day or two before defervescence, and in some 
instances a striking post-febrile eosinophilia develops. In 20 
cases showing marked leucocytosis, Billings found the following 
averages : lymphocytes, 9.6 per cent. ; polynuclear neutrophils, 
91.2 per cent. ; eosinophiles, 0.2 per cent. Heim 2 found a simi- 
lar degree of polynuclear neutrophile increase in 19 cases. In 
3 of Billings' counts in fatal cases showing no leucocytosis, it 
was found that the various forms of leucocytes remained in their 
normal relative proportions, this fact apparently tending to show 
that no attempt whatever was being made to resist the infection, 
such as an increase in the polymorphous forms and a decrease 
in the mononuclears would indicate, even in the absence of an 
increase in the total number of leucocytes. The leucocytes 
usually respond to the iodine reaction, most strikingly in cases 
with high leucocytosis. In such instances myelocytes are gener- 
ally numerous. 

In the pneumonias of children the possibility of lymphocytosis 
should be remembered, for although a true lymphocytosis is rare, 
it sometimes occurs, giving rise to false impressions, if clinical 
signs other than the examination of the blood are neglected. 
(See p. 197.) 

During the period of fever the blood plaques are markedly de- 
creased in number, and often, indeed, altogether disappear from 
the blood, but after the crisis they reappear in great abundance, 
the fresh specimen taken at this time often being flooded with 
these bodies. 

In atypical cases the presence of a well- 
Diagnosis. marked leucocytosis is a helpful sign in exclud- 
ing such conditions as serous pleurisy, enteric 
fever, typhus fever, malarial fever, and influenza. In the differ- 
entiation of croupous from catarrhal pneumonia, empyema, and 

1 Deut. med. Woch., 1900, vol. xxvi., p. 558. 

2 Archiv. de med. des enf., 1901, vol. iv., p. 21. 



4i6 



GENERAL HEMATOLOGY. 



acute meningitis the leucocyte count furnishes no tangible clue, 
since it is high in all these conditions ; the same is true of some 
cases of acute bronchitis. An acute apical pneumonia, if associ- 
ated with leucocytosis, is almost invariably to be considered non- 
tuberculous. 

As previously stated, absence of leucocytosis in a case with well- 
defined chest signs is of grave prognosis, but the presence of a 
leucocytosis is by no means always of good augury. Persistence 
of a high leucocyte count is suggestive either of delayed resolu- 
tion, empyema, or gangrene, and a sudden reestablishment of the 
leucocytosis, after its disappearance at the time of crisis, points to a 
recurrent attack of the disease. Reappearance of the eosinophiles 
or the presence of circulatory eosinophilia, indicates the termina- 
tion of the acute phase of the illness. 

Detection of the pneumococcus in the peripheral circulation is 
almost equivalent to signing the patient's death-warrant, although, 
on the contrary, negative results from blood cultures are of no 
significance. 

LII. POISONING. 

A synopsis of the blood changes produced by various toxic 
substances is given in the following table, these changes consist- 
ing chiefly in hemocytolysis, methemoglobinemia, anemia, poly- 
cythemia, and leucocytosis. 



Name of Poison. 
Alcohol. 
Amyl nitrite. 
Acetanilid. 
Ammonia. 
Antipyrin. 

Arseniuretted hydrogen. 

Aspidium. 

Bromine. 

Chloral. 

Chromic acid. 

Corrosive metals and minerals. 

Ether. 

Guiacol. 



Effects upon the Blood. 
Anemia ; often leucocytosis. 1 
Methemoglobinemia. 2 
Methemoglobinemia. 3 
Leucocytosis. 1 
Methemoglobinemia. 3 
Hemoglobinemia. 2 
Hemocytolysis. 4 
Methemoglobinemia. 5 
Leucocytosis. 1 
Methemoglobinemia. 2 
Anemia ; leucocytosis. 1 
Oligochromemia ; leucocytosis. 6 
Hemocytolysis ; leucocytosis. 7 



1 Cabot : loc. cit. 

2 Grawitz : loc. cit. 

3 Muller: Deut. med. Woch., 1887, vol. xiii., p. 27. 

* Georgiewsky : Beitr. z. path. Anat. u. z. allg. Path., 1898, vol. xxiv., p. I. 

5 Hayem : Compt. rend. Soc. biol., Paris, 1886, vol. cii. , p. 698. 

6 J. Chalmers DaCosta : Araer. Surg. Assn., Baltimore, May 7, 1901. 

7 Wyss : Deut. med. Woch., 1894, vol. xx., p. 296. 



RABIES. 



417 



Hydrocyanic acid. 
Illuminating gas. 

Iodine. 
Lead. 

Nitrobenzol. 

Nitroglycerine. 
Opium. 
Phenacetin. 
Phosphorus. 

Potassium chlorate. 

Potassium permanganate. 

Ptomaines. 

Pyrodin. 

Pyrogallol. 

Pyrogallic acid. 

Snake and scorpion venom. 

Sodium nitrite. 

Tansy. 

Toadstools. 

Toluene. 

Turpentine. 



Methemoglobinemia. 1 

Methemoglobinemia ; polycy- 
themia ; leucocytosis. 2 

Methemoglobinemia. 3 

Anemia ; granular basophilia ; 
often leucocytosis. 4 

Methemoglobinemia ; megalo- 
blastic anemia. 5 

Methemoglobinemia. 6 

Occasionally leucocytosis. 2 

Methemoglobinemia. 7 

Polycythemia ; occasionally leu- 
cocytosis. 8 

Methemoglobinemia ; anemia ; 
leucocytosis. 9 

Methemoglobinemia. 3 

Leucocytosis. 2 

Hemocytoly sis. 10 

Methemoglobinemia. 6 

Methemoglobinemia. 6 

Hemoglobinemia ; hypervis- 
cosity 11 ; leucocytosis. 12 

Methemoglobinemia. 6 

Leucocytosis. 2 

Hemoglobinemia. 1 

Hemoglobinemia. 13 

Methemoglobinemia. 3 



LIII. RABIES. 

Courmont and Lesieur 14 have recently determined that an ex- 
cessive increase in the number of polynnclear neiitropJules is a 
constant change in the blood of patients suffering from hydro- 



1 Robert : " Lehrb. d. Intoxicationen," Stuttgart, 1893. 

2 Cabot : loc. cit. 

3 Hayem: Compt. rend. Soc. biol. , Paris, 1886, vol. cii., p. 698. 

4 Grawitz and Hamel : Deut. Archiv. f. klin. Med., 1900, vol. lxvii., p. 357. 

5 Ehrlich and Lindenthal : Zeitschr. f. klin. Med., 1896, vol. xxx., p. 427. 

6 Grawitz : loc. cit. 

7 Kronig : Berl. klin. Wocb., 1898, vol. xxxii., p. 998. 

8 Von Jakscb : Deut. nied. Woch., 1893, vol. xix., p. 10. 

s Bradenburg : Berl. klin. Woch., 1895, vol. xxxii., p. 583. 

10 Tallquist : " Exper. Blut. gizt. Anemie," Berlin, 1900. 

11 Stengel : " Contributions from the William Pepper Laboratory of Clinical Medi- 
cine," Phila., 1900. 

12 Auche and Vaillant : Journ. de Med. de Bordeaux, 1 901, vol. xxxi., p. 29. 
™ Vast : " These de Paris," 1889. 
14 Sem. med., 1901, vol. xxi., p. 61. 

27 



4i8 



GENERAL HEMATOLOGY. 



phobia, and that analogous findings are met with experimentally 
in rabid dogs, guinea-pigs, and rabbits. The polynuclear gain is 
frequently, but not invariably, associated with an increase in the 
total number of leucocytes. It may amount to as much as 98 
per cent., and first develops during the period of incubation, be- 
coming emphasized with the appearance of the clinical symptoms 
of the affection, and reaching a maximum just before death. 
The authors referred to believe that an absence of polynucleosis 
is sufficient to rule out rabies in a suspected case, although its 
presence cannot be regarded as pathognomonic of the disease. 

LIV. RELAPSING FEVER. 

The specific cause of relapsing fever, a spiril- 
Parasitology. lum discovered by Obermeier in 1868, 1 may be 
found in the peripheral blood of patients suffer- 
ing from this disease, only during and shortly before the febrile 
paroxysm, the organism disappearing from the general circulation 
during the interparoxysmal afebrile period. The number of para- 



Fig. 48. 




Spirilla of relapsing fever. 



sites found in a blood-film varies within wide limits, and does not 
generally stand in any definite parallelism to the severity of the 
infection or to the degree of pyrexia. 

Microscopically, the spirilla of Obermeier appear in the fresh 
blood as delicate, homogeneous, thread-like bodies twisted into 
the form of spirals, occurring singly or in groups of several or- 

1 Centralbl. f. d. med. Wissensch., 1873, vol. xi., p. 145. 



RELAPSING FEVER. 



419 



ganisms, radiating from a common center. ( Fig. 48.) The 
length of the parasites varies from 16 to 40 a, or approximately 
from two to six times the size of the normal erythrocyte. They 
possess an active vibratile motility, exerted in the direction of 
their long axes, by virtue of which they are propelled and con- 
stantly altered in shape. Owing to this characteristic motility, 
the presence of the parasites is usually first betrayed to the ex- 
aminer by the whipping about of the blood corpuscles in their 
immediate proximity. The spirilla remain alive for only a short 
time after the withdrawal of the blood, and are so extremely 
sensitive to external influences that the addition even of distilled 
water causes them rapidly to disappear. Since nothing is known 
of their life history, the cause of their disappearance from the 
peripheral circulation during the intermissions of the disease is 
not known. 

Both Sarnow 1 and von Jaksch 2 have called attention to the 
presence of certain refractive bodies, similar to diplococci, which 
may be found in the blood during the intermission, provided that 
another paroxysm is impending. The last-named authority be- 
lieves that he has observed the metamorphosis of these bodies 
into short thick rods from which the typical spirilla eventually 
are evolved, and he tentatively regards them as spores of the 
latter. The views of this investigator have not, however, been 
generally accepted up to the present time. 

Afanassiew 3 has described, in addition to the specific spirilla, 
peculiar bacteria which he found in the blood during the parox- 
ysm. The organisms in question resemble bacilli with rounded 
poles, and appeared to be invested by non-staining, hyaline 
sheaths. Some of them measured not more than 5 or 6 fi in 
length, while others appeared as filamentous threads fully 10, 12, 
or 1 4 JUL long, this increase in size being demonstrable in the fresh 
specimen watched for some time under the microscope. Afanas- 
siew asserts that, unlike Obermeier's spirilla, the bodies may be 
cultivated on bouillon, gelatine, agar, and blood serum ; he further 
claims that in three patients inoculated with a twenty-four-hour- 
old bouillon culture of the organism, periods of pyrexia, recurring 
at ten-day intervals, were produced, and that in the blood of one 
of the patients thus treated numerous bacillary and filamentous 
forms were discovered. These investigations, as yet unconfirmed 
by other workers, are to be regarded only in the light of an in- 
teresting observation. 

1 Inaug. Dissert., Leipzig, 1882. 

2 " Clinical Diagnosis," 3d ed., London and Phila., 1897, p. 50. 
3 Centralbl. f. Bakt. u. Parasit., 1899, vol. xxv., p. 273. 



420 



GENERAL HEMATOLOGY. 



Melanin granules, either free or within the protoplasm of the 
leucocytes, are frequently seen in the blood, especially just after a 
paroxysm, and phagocytes containing engulfed spirilla may also 
be found at this time. 

Technique of Examination. Fresh specimens of blood, taken 
during the paroxysm from the patient's finger or ear, are most suit- 
able for microscopical examination. The motility and finer struc- 
ture of the spirilla are seen most clearly with a inch oil-immer- 
sion objective, but for making the preliminary search a lower power, 
dry lens is more convenient, a| ori inch objective being useful 
for this purpose. 

Dried films, fixed by one of the chemical methods of fixation 
already described (page 62) may be stained preferably by fuch- 
sin, or the method of Gunther (page 86) may be used. For 
diagnostic purposes stained specimens are never to be preferred 
to the fresh blood film. 

LoiventhaV s Reaction. The ingenious blood test devised by 
Lowenthal 1 furnishes a means of recognizing relapsing fever dur- 
ing the afebrile period, when the spirilla cannot be detected in the 
blood. It is conducted in the following manner. A drop of 
blood from a suspected case is mixed with a drop containing 
motile spirilla, the latter being taken from a patient during the 
paroxysmal stage of the disease. The mixture thus made is 
sealed between a slide and cover-glass, and incubated at body 
temperature for half-an-hour, at the end of which time it is ex- 
amined under the microscope. If the suspected case be one of 
relapsing fever, the spirilla will have become quite motionless and 
collected together in irregular masses, while if the case be one of 
some other disease the motility of the parasites remains unim- 
paired. A control specimen, prepared from normal and spirilla- 
containing blood, must always be similarly incubated and ex- 
amined with each test. If no such reaction as that described 
occurs within a time limit of two hours and one-half at the most, 
it is safe to regard the suspicious case as one not of relapsing 
fever. In 35 cases of this disease, Lowenthal obtained about 85 
per cent, of positive results, while in 14 cases of fever due to 
other causes the reaction was uniformly absent. 

The reaction, which takes place in abortive and mild cases as 
well as in the severer forms of the disease, is thought to be de- 
pendent upon the presence in the blood of specific bactericidal 
products. 

1 Deut. med. Woch., 1897, vol. xxiii., p. 560. 



RHEUMATIC FEVER. 



421 



Von Limbeck, 1 quoting von Bockmann, states 
Hemoglobin that there is a decrease in the number of erythro- 
and cytes and in the hemoglobin value in cases of re- 
Erythrocytes. lapsing fever, but neither the mode of production 
of such an anemia, nor the exact morphological 
changes by which it is characterized, have been carefully investi- 
gated, so far as can be ascertained. The losses are observed to 
occur during and for a few days after each paroxysm, but they 
are partly compensated during the interparoxysmal period. 

A variable degree of increase in the number of 
Leucocytes, leucocytes, often of high grade, has been described 
by Laptschinski 2 as associated with the paroxys- 
mal stage of the disease, this observer having noted that the 
" coarsely granular elements" were especially involved, and that 
the relative number of leucocytes to erythrocytes was in some 
instances as high as 1 to 37. During the period of intermission 
this leucocytosis disappears. This author, as well as von Bock- 
mann 3 and Heidenrich, 4 also noted that the period of maximum 
leucocytosis was reached just after the crisis. 

The detection of the spirillum in the blood im- 
Diagnosis. mediately differentiates relapsing fever from typhus 
fever, the onset and initial symptoms of which not 
infrequently prove confusing, and it may also be added that in such 
instances the absence of this organism during the stage of pyrexia 
is strong evidence for excluding the first-named disease. During 
the afebrile period, when the symptoms may suggest, for ex- 
ample, malarial fever, Lowenthal's reaction should be attempted, 
and the malarial parasite searched for. Melanemia, it must be 
recalled, may be encountered in both of these infections. 

LV. RHEUMATIC FEVER. 

Coagulation of the blood takes place within the 
General normal time limit, or it may be delayed consider- 
Features. ably. The amount of fibrin is markedly in- 
creased, especially during the most acute stages 01 
the illness. Contradictory reports have been made by different 
authors concerning the alkalinity, some having found it dimin- 
ished, and others having been unable to detect any such altera- 
tion. According to Hutchinson, 5 the general consensus of opin- 

1 Loc. cit. 

2 Centralbl. f. d. med. Wissensch., 1875, vol. xiii., p. 36. 
3 Loc. cit. 

i " Untersuch. u. d. Par. d. Riickfallstyphus," Berlin, 1877. 
5 Lancet, 1896, vol. i., p. 615. 



422 



GENERAL HEMATOLOGY. 



ion is against any notable disturbance of the normal figure. In 
chronic articular rheumatism with coexisting anemia a slight dim- 
inution of the alkalinity is occasionally observed. 

The bacteriology of the blood in this disease has for many 
years been the object of much careful study, but thus far specific 
properties have not been generally conceded to any definite or- 
ganism, although a great number of different bacilli, streptococci, 
staphylococci, and diplococci have been cultivated from the circu- 
lating blood during life. At the present time the bacillus iso- 
lated by Achalme 1 and the diplococcus of Triboulet 2 are regarded 
by many, especially by some of the French school, as possible 
etiological factors, if, indeed, rheumatic fever is actually a bacterial 
disease. For a careful review of the bacteriology of rheumatism 
the reader should consult the admirable brochure, " Le Rhu- 
matisme articulaire aigu en bacteriologie," by Triboulet and 
Coyon, Paris, 1900. 

Few cases of acute rheumatic fever are unac- 
Hemoglobin companied by anemia, the intensity of which 
and generally bears a fairly close relation to the se- 
Erythrocytes. verity and the duration of the illness. In acute 
attacks of short duration the hemoglobin falls to 
about 70 or 80 per cent, and the erythrocytes to 4,000,000, but 
in cases of longer standing the losses are likely to be more pro- 
nounced, the count often being not more than 3,000,000 or 
thereabouts. The color index usually is moderately subnor- 
mal, and may tend to remain so after the attack, even though the 
rise normalward of the erythrocyte count may have become well 
established. In chronic rheumatism a moderate oligochromemia 
is usually the only evidence of anemia that can be detected, un- 
less the patient happens to be decidedly cachectic. 

Cabot's 43 cases of acute rheumatic fever 3 showed an average 
hemoglobin estimate of 67 per cent., and an average erythrocyte 
count of 4,400,000 per cubic millimeter. In the writer's experi- 
ence, limited to 7 cases, the anemia was found to be much more 
striking, for in two the hemoglobin estimates were 26 and 30 per 
cent., and the counts 1,242,000 and 1,590,000, respectively. 
These figures were sufficient to lower the averages for the total 
number to 47.6 per cent, for hemoglobin, and 3,098,964 per cubic 
millimeter for the erythrocytes. 

1 Compt. rend. Soc. biol., Paris, 1891, 9 s., vol. iii., p. 651. Ibid., 1897, 10 s., 

vol. iv., pp. 276 and 1000. 

^Rev. de med., Paris, 1888, vol. xviii., pp. 189 and 329. Also, Triboulet, Coyon 
and Zadoc : Bull. Soc. med. des hop. de Paris, 1897, 3 s., vol. xiv., p. 1343. 

3 Loc. cit. 



SCARLET FEVER. 



423 



Should the cellular loss reach a high grade, deformities of 
shape and size, polychromatophilia, and, rarely, nucleated erythro- 
cytes of the normoblastic type may be observed. 

Leucocytosis of the typical polynuclear neutro- 
Leucocytes. phile type is almost always present during the 
acute stages, but it is found only exceptionally in 
the subacute form of rheumatism, and practically never exists in 
the chronic variety. The count does not often exceed twice the 
maximum number of cells found normally, but occasionally it 
reaches a figure as high as 30,000 or 40,000 per cubic millimeter, 
especially in very acute cases, which as a rule are associated 
with the highest leucocytoses. In Cabot's cases, above referred 
to, the number of leucocytes averaged 16,800, and ranged from 
4,700 to 39,000. In the writer's cases the maximum count was 
31,200, the minimum 8,000, and the average 14,857. 

Turk 1 has noticed that in many instances well-marked post- 
febrile eosinophilic^ develops, and that in favorable cases a relatively 
high percentage of eosinophiles persists during the acute stage 
of pyrexia. 

The blood changes are uncharacteristic, and do 
Diagnosis. not serve as a means of differentiating this condi- 
tion from other lesions in which the joint involve- 
ment and the constitutional manifestations are more or less similar. 
Thus, in acute gout, in multiple secondary arthritis, and in septic 
arthritis due to pyemia, the same grade of anemia, leucocytosis, 
and hyperinosis may be observed. 

LVI. SCARLET FEVER. 

In cases associated with pronounced anginal 
General symptoms and with marked leucocytosis, coagu- 
Features. lation of the fresh blood drop is rapid, and the 
amount of fibrin decidedly in excess of normal. 
In many cases a slight increase of fibrin is observed at the period 
of beginning desquamation. 

The specific gravity is unchanged in the average case, but in 
those complicated by acute parenchymatous nephritis, in conse- 
quence of the drain on the albuminoids of the blood thus pro- 
duced, it may fall to a very low figure — to 1030, according to 
Peiper and Hammerschlag. 2 In 12 cases studied by van den 
Berg, 3 the specific gravity ranged from 1031 in complicated 
cases, to 1060 in uncomplicated cases of the average severity. 

1 Loc. cit. 

2 Centralbl. f. klin. Med., 1891, vol. xii., pp. 217 and 825. 
3 Archiv. f. Kinderheilk. , 1898, vol. xxv., p. 321. 



424 



GENERAL HEMATOLOGY. 



The specific micro-organism of scarlet fever 
Bacteriology, has not yet been isolated, either from the blood 
or other tissues, although in recent years many 
different bacteria have been described as causative factors. 
Class 1 claims to have discovered in the blood and throats of 
scarlet fever patients a diplococcus, named by him the diplococcus 
scarlatina, which he considers specific, and this claim has received 
the support of a number of other investigators, Gradwohl, 2 
Jaques, 3 and Page 4 being among those who found the bac- 
terium in question. Baginsky and Sommerfeld 5 conclude, as 
have some earlier writers, that the clinical features of scarlet 
fever are due to a general streptococcus infection, having found 
this organism in the blood of 42 fatal cases. Class, 6 in a later 
communication, hints that his diplococcus and Baginsky and Som- 
merfeld's streptococcus are identical, since the former often de- 
velops streptococcus forms in young cultures made from the 
blood. Any one who has read Class' description of his organ- 
ism must be struck with its resemblance to the diplococcus found 
in scarlet fever blood by Crajkowski, 7 in 1895. Jehle 8 states 
that he has repeatedly isolated the influenza bacillus from the 
blood of young children ill with scarlet fever. The studies of 
these investigators, while of the greatest interest, are scarcely 
conclusive. 

Most observers agree that the scarlatinal infec- 
Hemoglobin tion, unless complicated, produces but trifling 
and changes in the hemoglobin and erythrocytes, 
Erythrocytes, moderate anemia characterized by a dispropor- 
tionate diminution of hemoglobin being the gen- 
eral rule in the cases in which any changes are noted. 

Widowitz 9 found that the percentage of hemoglobin, normal 
at the beginning of the illness, slowly diminished during the fe- 
brile period, in a degree commensurate to the intensity of infec- 
tion, and gradually returned to normal during convalescence. 
Pee 10 noticed, in severe cases, a pronounced " chloro-anemia," 
characterized by notable pallor and variations in the size of the 
corpuscles. Hemoglobinemia has also been occasionally observed. 

1 N. Y. Med. Record, 1899, vol. lvi., p. 330. 
2 Phila. Med. Journ., 1900, vol. iv., p. 688. 
3 Ibid., p. 552. 

4 Journ. Bost. Soc. Med. Sc., 1899, vol. iii., p. 344. 
6 Berl. klin. Woch., 1900, vol. xxxvii., p. 588. 
6 Journ. Am. Med. Assn., 1900, vol. xxxv., p. 799. 
7 Centralbl. f. Bakt. u. Parasit , 1895, vol xviii., p. 116. 
8 Zeitschr. f. Heilk., 1901, vol. xxii., p. 190. 

9 Jahrb. f. Kinderheilk. , 1888, vol. xxvii., p. 380; vol. xxviii., p. 25. 
10 Inaug. Dissert., Berlin, 1890. 



SCARLET FEVER. 



425 



The number of erythrocytes is generally between 4,000,000 
and 5,000,000 per cubic millimeter in the case of average se- 
verity, the minimum count being reached at about the time of 
the decline of the temperature ; but in complicated cases the 
anemia is more marked, and histological degenerative changes 
of the corpuscles have been noted during the period of desqua- 
mation. Van den Berg's examinations of 12 cases 1 show that 
the count is usually above 4,000,000 per cubic millimeter, except 
in severe cases complicated by acute nephritis, or endocarditis, 
in the event of which a rapid and striking anemia is produced, 
the hemoglobin sometimes being as low as 25 per cent., and the 
corpuscles diminishing to as low as 2,000,000 per cubic milli- 
meter. From an analysis of the cases reported by Zappert, 2 
Felsenthal, 3 Widowitz, 4 and others, the average loss of erythro- 
cytes in all cases amounts to about 1,000,000 cells to the cubic 
millimeter, but Kochetkoff 5 notes a more decided average reduc- 
tion, this author stating that they progressively decrease to about 
3,000,000, and that regeneration is slow and gradual, not being 
completed for a period of six weeks. 

A well-marked leucocytosis, the count usually 
Leucocytes, ranging between 20,000 and 30,000 per cubic 
millimeter, occurs in the majority of cases, often 
first appearing several days in advance of the cutaneous eruption, 
and persisting in some cases long after convalescence has been 
established. Its duration varies widely in different instances ; in 
some cases, not necessarily of a severe type, the leucocytosis 
persists for ten, or even thirty days ; while in others, usually of a 
mild type, it disappears before the temperature has fallen to 
normal. The maximum degree of increase is reached from four 
to six days after the onset of the illness. 

In asthenic cases the number of leucocytes is increased but 
slightly, or not at all ; but in the well-nourished child, the degree 
of leucocytosis may be regarded as a rough gauge of the intensity 
of the infection, being usually greater in severe than in mild cases. 
The increase appears to bear no fixed relationship either to the 
anginal infection, or to the glandular involvement, for marked leu- 
cocytosis has been observed in cases with mild angina, unac- 
companied by swelling of the glands. Neither can any clear re- 
lation be established between the leucocytosis and the character 

1 Loc. cit. 

2 Zeitschr. f. klin. Med., 1893, vol. xiii., p. 292. 
3 Archiv. f. Kinderheilk., 1 892-3, vol. xv., p. 82. 

4 Loc. cit. 

5 Vrach, 1891, vol. xii., p. 919. 



426 



GENERAL HEMATOLOGY. 



of the temperature, the period of desquamation, and the inflam- 
matory complications of the ear and kidney. 

In all of van den Berg's cases the number of leucocytes was 
in excess of normal, the " first counts" averaging slightly more 
than 17,000 per cubic millimeter, and the leucocytosis being 
higher than 30,000 in only 2 cases. The investigations of the 
other authors above referred to give practically the same results, 
although somewhat higher counts have been made in some in- 
stances. Mackie 1 found leucocytosis constant in 25 cases, and 
in one patient with severe anginal symptoms the count rose to 
93,300. He failed to observe any signs of a leucocyte increase 
until twenty -four hours after the appearance of the rash. 

The leucocytosis is generally due to an increase in the poly- 
nuclear neutrophils, these cells ranging from 85 to 90 per cent.; 
but in some instances the increase is more evenly divided between 
the polymorphous and mononuclear forms, so that from 70 to 
80 per cent, of the former and from 15 to 30 per cent, of the 
latter may be found. The writer has noticed the presence of 
large numbers of the so-called transitio?ial mononuclear leu- 
cocytes, and of an occasional myelocyte. Van den Berg has 
noted the presence of small numbers of myelocytes in grave 
cases. Contrary to the rule which holds good in most febrile 
conditions, the number of eosinophiles in favorable cases of scarlet 
fever remains normal, or, indeed, may be decidedly increased. 
In very grave cases a decrease or absence of these cells is usually 
found. In cases with nephritic complications their increase is 
thought to be favorable. The proportion of eosinophiles is us- 
ually from 4 to 5 per cent, of the other forms, sometimes even 
10 or 15 per cent., especially during the post-febrile period of 
the disease. 

The blood plaques are normal at the beginning of the attack, 
but a large increase in the number of these elements is said to 
occur during the period of desquamation. 

The presence of leucocytosis and persistence 
Diagnosis, of the eosinophiles, are suggestive signs in distin- 
guishing scarlet fever from measles, since in un- 
complicated cases of the latter disease these changes are absent. 
Disappearance of the eosinophiles is regarded as a bad prognos- 
tic sign. 

1 Lancet, 1901, vol. ii., p. 525. 



SEPTICEMIA AND PYEMIA. 



42; 



LVII. SEPTICEMIA AND PYEMIA. 

The blood changes found in those conditions 
General due to the presence in the circulating blood of 
Features. septic bacteria or their toxines, general septicemia, 
sapremia, and pyemia, are similar, and therefore 
may be considered together under the above heading. An ap- 
parently trivial infected wound may give rise to just as severe 
blood changes as an intense pyemia with widespread metastatic 
abscesses, since these alterations depend rather upon the virulence 
of the infection and the reaction which it provokes, than upon the 
character of the exciting lesion and the specific nature of the 
offending organisms. Clinically, these blood changes may be 
associated with such conditions as infected wounds, osteomyelitis, 
malignant endocarditis, puerperal fever, septic joints, and many 
other lesions for which various septic micro-organisms are held 
responsible. 

The amount of fibrin is often appreciably increased in cases in 
which the reaction against the infection is well marked, especially 
in the early stages of the illness. A decrease in fibrin is, how- 
ever, common in patients with pronounced anemia, and in those 
who readily succumb without reaction against the infection. 

Thus far, the serum test has given no reliable clinical informa- 
tion in this class of diseases, although several clinicians of the 
French school claim occasionally to have observed typical clump- 
ing of streptococcus bouillon cultures with the serum of patients 
suffering from streptococcus infections, such as streptococcus in- 
fected wounds, sepsis, puerperal fever, and erysipelas ; but nega- 
tive results were obtained in testing bouillon cultures of the 
staphylococcus with the serum of staphylococcus septicemia. 
The evidence brought forward to show that the serum of 
patients suffering from colon infections clumps cultures of the 
colon bacillus, is by no means conclusive ; for many races of the 
colon bacillus, it may be recalled, clump spontaneously, and are 
agglutinated by normal serum. If a test-tube containing blood 
serum of a patient suffering from pneumococcus septicemia is 
inoculated with a pure culture of the pneumococcus, it will be 
found that, after twenty-four hours' incubation, the serum still 
remains free from turbidity, and shows simply a slight sediment 
composed of pneumococci, capsuleless and glued together in 
tenacious clumps, or in serpentine, trailing designs. Pneumococci 
grown in normal serum cloud the liquid, and develop a new 
growth consisting of encapsulated, isolated organisms. Favorable 



428 



GENERAL HEMATOLOGY. 



results have been reported by several Continental writers who 
have used this test clinically, but its diagnostic value must still be 
regarded as questionable. 

In the great majority of cases of septicemia 
Bacteriology, and pyemia, cultures from the blood prove ster- 
ile, but such negative results neither exclude the 
existence of a septic process, nor necessarily indicate a favorable 
prognosis. On the other hand, positive results are often of the 
greatest value in the diagnosis of obscure cases of sepsis, in 
which the clinical manifestations are more or less vague. As 
pointed out by Welch, 1 blood cultures in which the staphylococ- 
cus pyogenes albus is demonstrated have little significance in the 
prognosis of the case, whereas the presence in the blood of the 
other pyogenic cocci is almost invariably a grave sign. 

The results obtained by different investigators in the bacterio- 
logical examination of the blood in septicemia vary within wide 
limits, these variations being explained partly by the differences 
in the technical methods used by each reporter, and partly per- 
haps by the nature of the infection. Petruschky 2 obtained 17 
positive results in the examination of 59 cases of sepsis, strepto- 
cocci being found in 15, and staphylococci in 2 instances. Sitt- 
man 3 examined 53 cases of septicemia, and succeeded in iso- 
lating streptococci in 4, staphylococci in 1 1, and pneumococci in 
6. Czerniewski 4 in 37 cases of puerperal sepsis obtained posi- 
tive results in 10, pure cultures of streptococci being found in all 
the grave infections. Symes 5 obtained positive cultures in 9 out 
of 3 1 cases of sepsis, the staphylococcus, the streptococcus, the 
pneumococcus, and the micrococcus tetragenus having been the 
organisms identified. Kiihnau's investigations 6 show a much 
lower percentage of positive findings than are commonly re- 
ported, for this author in 23 cases of septico-pyemia obtained 
growths in only 3 instances, while but a single positive finding 
resulted from the examination of 1 2 cases of ulcerative endo- 
carditis. Krauss, 7 who has had a very large experience in the 
bacteriological investigation of the blood in various infectious 
diseases, reports 7 positive results in a series of 22 cases of sep- 
ticemia, ulcerative endocarditis, and erysipelas. White 8 in 18 

1 Dennis' "System of Surgery," Phila., 1895," vol. i., p. 251. 

2 Zeitschr. f. Hygiene, 1894, vol. xvii., p. 59. 
3 Deut. Archiv. f. klin. Med., 1894, vol. liii., p. 323. 

4 Archiv. f. Gynaekol., 1888, vol. xxxiii. , p. 73. 

5 British Med. Joum., 1901, vol. ii., p. 709. 

6 Zeitschr. f. Hygiene, 1897, vol. xxv., p. 492. 

7 Zeitschr. f. Heilk., 1896, vol. xvii., p. 117. 
8 Journ. of Exper. Med., 1899, vol. iv., p 425. 



SEPTICEMIA AND PYEMIA. 



429 



severe cases of sepsis, all of which were fatal, obtained positive 
findings in 4 ; the streptococcus pyogenes 3 times, and the 
staphylococcus pyogenes aureus once. Canon 1 obtained 1 1 
positive results in the examination of 17 cases of septicemia, 
pyemia, and osteomyelitis. Hirschlaff 2 obtained the streptococcus 
or staphylococcus 7 times, in cultures made from 8 cases of 
sepsis. James and Tuttle 3 in 6 severe septic infections suc- 
ceeded in finding the streptococcus in 2 instances. Brieger 4 
obtained uniformly negative findings in the examination of 6 
cases of puerperal sepsis. Similar results have also been re- 
ported by Neumann 5 who obtained negative findings in blood 
cultures from 5 cases of pyemia. Grawitz 6 cultured pyogenic 
cocci only once in his examination of 7 cases of malignant en- 
docarditis. 

Consideration of these figures, together with the statistics of a 
number of other reporters of smaller series of cases, furnishes a 
total of 316 cases of sepsis in which it is reasonable to presume 
that the bacteriological examination of the blood has been made 
by dependable methods. Of these 316 cases, positive results 
were obtained in 107, while the remaining 209 proved negative — a 
percentage of 33.8 for the former. This analysis, however, is not 
to be regarded as equivalent to the statement that bacteriological 
examination of the blood gives positive diagnostic information in 
one-third of all cases, for the results of a single reliable observer, 
rather than the aggregate figures of several, are to be considered 
in order to arrive at a true estimate of the value of this procedure. 
The writer is inclined to believe that White's results accurately 
express the value of blood cultures in this class of infections. 

Anemia, of a grade proportionate to the inten- 
Hemoglobin sity of the infection, is the rule in septic cases, 
and regardless of the specific nature of the infective 
Erythrocytes, process. In very acute cases the diminution ot 
hemoglobin and erythrocytes may be so excessive 
and so rapid that an abrupt downward curve in the erythrocyte 
line of the blood chart may be detected from day to day, even 
from morning until night, in some instances. This rapidly de- 
veloping type of anemia is associated especially with fulminant 
cases of puerperal septicemia, in which counts of less than 1,000,- 
000 cells per cubic millimeter have been frequently reported. 

1 Deut. Zeitschr. f. Chirurg., 1893, vo ^- xxxvii., p. 571. 

2 Deut. med. Woch., 1897, vol. xxiii., p. 766. 
3 Loc. cit. 

4 Charite-Annal., 1888, vol. xiii., p. 198. 
5 Berl. klin. Woch., 1888, vol. xxv., p. 143. 
6 Charite-Annal., 1894, vol. xix., p. 154. 



43Q 



GENERAL HEMATOLOGY. 



In less severe cases the development of the anemia is slower 
and of a more moderate grade, the hemoglobin being reduced to 
40 or 50 per cent., and the erythrocytes to from about 2,500,000 
to 3,500,000 per cubic millimeter. 

The following estimates show the blood changes found in a 
case of puerperal sepsis during a period of four months : 





Hemoglobin 


Erythrocytes 


Leucocytes 


Date. 


Percentage. 


PER CB. MM. 


PER CB. MM, 


4-29-OI. 


57 


3,380,000 


17,200 


5-I6-OI. 


52 


3,390,000 


14, 200 


6- 2-01. 


38 


2,640,000 


29,400 


6- 9-01. 


22 


2,000,000 


33>i°° 


6-1 2-0 1. 


2 5 


1,600,000 


19,000 


6-16— 01. 


30 


1,850,000 


16,800 


6— 21-01. 


2 5 


1,902,250 


27,200 


6-27-01. 


35 


2 ,339> 000 


19,200 


7- 5-0 1. 


3° 


2,050,000 


8,600 


7-22-01. 


30 


2,300,000 


6,000 


8- 6-01. 


35 


3,150,000 


15,000 


8-1 5-0 1. 


39 


3,787,000 


10,500 


8-22-01. 


48 


3,637,000 


9,200 


8-25-01. 


5 2 


3,899,000 


9,000 



oglobin and erythrocyte values were as follows : 

Erythrocytes. 



Hemoglobin. 


Cases. 




From 60 to 70 per cent. 


2 


Above 


" 50 to 60 " " 


3 


From 


" 40 to 50 " " 


8 




" 30 to 40 " " 


3 


a 


" 20 to 30 " " 


4 


1 1 


Below 20 " " 


1 





3,000,000 to 4,000,000 
2,000,000 to 3,000,000 
1,000,000 to 2,000,000 



Cases. 
I 

3 
8 

7 

2 



Average: 42.4 per cent. Average 
Highest: 64 " " Highest 
Lowest: 19 " " Lowest: 



3,150,490 per cb. mm. 
5,390,000 " " " 
1,093,000 " " " 



The color index is usually quite low, for the hemoglobin loss 
is as a rule relatively greater than the corpuscular decrease ; it 
averaged 0.67 for this series. Hemoglobinemia may be recognized 
in occasional instances of grave character. Most writers lay stress 
on the excessively watery condition of the serum, particularly in 
those cases in which the development of anemia is early, marked, 
and rapid. 

Deformities of shape and size and atypical staining phenomena 
are marked in relation to the degree of the anemia ; they are 



SEPTICEMIA AND PYEMIA. 



431 



rarely conspicuous, except in long-standing cases. The same re- 
marks apply to the presence of nucleated erythrocytes. Granular 
basophilia is found with more or less constancy, in severe cases. 

Leucocytosis is always present in those cases 

Leucocytes, in which the infection, either moderate or marked, 
occurs in a patient whose pqwers of resistance are 
sufficiently strong to react against the poison. The increase in 
the number of leucocytes is usually moderate — from about 1 5,000 
to 25,000 in the average case. In trifling infections, not suf- 
ficiently marked to produce activity of the leucocyte-forming 
organs, and in lethal cases, in which the system is overwhelmed 
by the toxines, not only does leucocytosis fail to develop, but in 
some instances distinct leucopenia may be observed. These facts 
render the occurrence of leucocytosis in septicemia an extremely 
inconstant sign, for it is no uncommon experience to examine case 
after case of undoubted sepsis, without encountering any increase 
in the leucocytes above normal. Thus, in the above series 
frank leucocytosis was found in only 12 instances, or but a trifle 
more than 55 per cent., while in 4 cases, or nearly 20 per cent., 
there was distinct leucopenia, the court in one being only 2,000 
per cubic millimeter. All the cases not showing leucocytosis 
were either very mild or very severe infections. 

In tabular form these cases may be summarized as follows : 

Above 20,000 in 2 cases. 

From 15,000-20,000 " 5 " 

" 10,000-15,000 " 5 " 

" 5,000—10,000 " 5 u 
Below 5,000 "4 " 

Average of 21 cases: 13,852 per cb. mm. 

" " 12 " with leucocytosis : 18, 793 per cb. mm. 
Highest: 41,600 per cb. mm. 
Lowest : 2,000 per cb. mm. 

The increase affects chiefly the poly nuclear neutropJiiles , which 
are both relatively and absolutely increased at the expense of the 
mononuclear forms. In a profoundly anemic case of sepsis Kline 1 
found striking eosinophilia — 40 per cent. In all forms of sepsis, 
and especially in puerperal fever, the iodine reaction occurs with 
great constancy. 

The value of the blood examination as an aid to 
Diagnosis, the diagnosis of septic conditions must be regarded 
as more or less uncertain. In cases with clinical 
manifestations suggesting at once enteric fever, malarial fever, 
and septicemia, the presence of leucocytosis is highly suggestive 

1 Centralbl. f. inn. Med., 1899, vol. xx., p. 97. 



432 



GENERAL HEMATOLOGY. 



of the latter condition, for in typhoid and in malaria leucocytosis 
rarely exists, except in the event of some complication. The 
early development of a rapidly increasing anemia would also point 
to sepsis rather than to typhoid or malaria, for in the latter fevers 
the anemia, although it begins early, does not reach a high grade 
until comparatively late in the course of the illness. The pres- 
ence of a positive serum reaction, or the discovery of malarial 
parasites in the blood will, of course, at once determine the 
diagnosis. If the diagnosis lies between sepsis and miliary tuber- 
culosis, increase in the number of leucocytes points to the former. 

In cases without leucocytosis, and these, unfortunately, are most 
common, the results of the blood examination are necessarily 
valueless, unless positive bacteriological findings should be ob- 
tained. The latter, after all, are the only absolutely dependable 
signs to be obtained from the study of the blood in this class 
of cases. 

LVIII. SYPHILIS. 

During the early stages of the infection, in the 
Hemoglobin interval between the appearance of the initial 
and lesion and the development of secondary symp- 

Erythrocytes. toms, the blood changes closely counterfeit those 
of typical chlorosis, a fact which has led to the 
use of the term "syphilitic chlorosis," to describe the blood- 
picture of early lues. The hemoglobin progressively falls until 
the loss approximates twenty or thirty per cent., while the num- 
ber of erythrocytes remains normal, or is but slightly diminished, 
in consequence of which the color index is low. As secondary 
symptoms appear, oligocythemia usually develops, and in some 
instances reaches a high grade. There is a close relationship 
between the intensity of the infection and the intensity of the 
anemia. In the tertiary and hereditary forms of the disease the 
count may fall to approximately one million cells, and the hemo- 
globin to twenty per cent, or even less, while extreme poikilo- 
cytosis, megalocytosis, and microcytosis may be present, together 
with numerous normoblasts and, perhaps, a few megaloblasts — 
the so-called " syphilitic pernicious anemia." 

After the administration of mercury both the hemoglobin and 
erythrocytes begin to increase, the former more slowly than the 
latter, until treatment has been continued for about two or three 
weeks, but should this drug be given for longer than this 
period, just the opposite effect is produced, first a diminution 
in the hemoglobin percentage, followed later by oligocythemia. 
Extreme hemoglobin loss under such a circumstance is regarded 



SYPHILIS. 



433 



as prognostic of severe tertiary manifestations, as the infection 
matures. The intravenous injection of mercuric chloride rapidly 
causes hemoglobinemia in syphilitics. It is a well-recognized 
clinical fact that the blood changes provoked by syphilis are likely 
to be more marked in women than in men, other things being 
equal. 

Justus* Test. This reaction, described by Justus, 1 depends 
upon the presumption that in untreated cases of congenital, 
secondary, and tertiary syphilis, a single dose of mercury, ad- 
ministered either by inunction, or by subcutaneous or intravenous 
injection, causes a hemoglobin loss of from ten to twenty per 
cent, within about twenty-four hours, this abrupt decline being 
followed within a few days by a rise in the hemoglobin value to 
a somewhat higher figure than that first observed, before the 
drug was given. Justus obtained uniformly positive results in 
more than 300 cases of syphilis, and negative results in a large 
number of n on -syphilitic control cases. Cabot and Mertins 2 ob- 
tained positive results in 7 syphilitics, and also in one case of 
chlorosis and in one of tertian malarial fever, but in their hands 
the test proved negative in 32 control cases of other diseases. 
Regarding the exceptional non-syphilitic diseases in which the 
reaction may prove positive, Brown and Dale 3 state that such 
cases are characterized by striking oligochromemia. A thor- 
ough study of the test has recently been made by Jones, 4 who 
examined 53 cases, of which number 35 were syphilis, and 18 
cases of other diseases. Of the former, 17 were active syphilis 
untreated, and of these the test was positive in 1 3 and negative 
in 4 ; fifteen cases of chancre yielded but 7 positive results, these 
occurring most frequently in chancre with adenitis ; in two cases 
of latent syphilis and in one of active syphilis under treatment 
the test failed. In the writer's experience, limited to 9 cases, the 
success of the test has been uniform. 

The diagnostic value of Justus' test is greatly restricted by its 
frequent failure in early initial lesions and in latent syphilis, and 
its occasional failure in the early part of the secondary stage, 
periods when a pathognomonic test would prove of the greatest 
aid. The fact that positive reactions may occur in non-syphilitic 
diseases must also be remembered. 

1 Verhandl. d. 5. Cong. d. Deut. dermatol. Gesellsch., Sep., 1895. Also Virchow's 
Archiv., 1894, vol. cxl., pp. 91 and 533. 

2 Boston Med. & Surg. Journ., 1899, vol. cxl., p. 323. 

3 Cincinnati Lancet-Clinic, 1900, vol. xliv., p. 261. 
4 N. Y. Med. Journ., 1900, vol. lxxi., p. 513. 



L>8 



434 



GENERAL HEMATOLOGY. 



The number of leucocytes, which remains ap- 
Leucocytes. proximately normal during the preemptive stage 
of the disease, usually increases moderately with 
the appearance of the secondary symptoms. Their total number 
rarely equals twice the maximum normal standard, and the gain 
is due, in the great majority of instances, to an increase in the 
non-granular hyaline forms, the percentage of polynuclear neutro- 
philes being relatively low. Many authors maintain that the 
eosinophiles are increased, but Peter, 1 who has especially investi- 
gated this question, emphatically states that in no form and at no 
stage of syphilis has he observed eosinophilia. In the leucocyte 
increase frequently found in the high-grade anemia of tertiary 
syphilis the lymphocytosis is especially striking, and the presence 
of small numbers of myelocytes is common. Under the influence 
of mercurial or iodide treatment the leucocyte count diminishes, 
the lymphocytes decrease, and the polynuclear neutrophiles grow 
more numerous. 

But slight diagnostic value can be attached to 
Diagnosis, the changes in the blood in this disease. The 
association of a low color index and a leucocyte 
increase chiefly of the lymphocytes, is suggestive, but nothing 
more. Justus' test, if positive, strengthens the pertinence of the 
preceding signs, provided that all sources of fallacy can be ex- 
cluded ; absence of the reaction by no means excludes syphilis. 
The distinctions between tertiary syphilitic anemia and true per- 
nicious anemia have already been discussed. (See page 230.) 

LIX. TETANUS. 

In a single fatal case, treated with antitoxin, Cabot 2 found 70 
per cent, of hemoglobin and 11,900 leucocytes per cubic milli- 
meter, with no decrease in the number of eosinophiles, as is 
usual in most febrile states. 

LX. TONSILLITIS. 

As a general rule, no appreciable changes are found in the 
hemoglobin and erythrocytes, although in severe cases the former 
is sometimes diminished. Leucocytosis of a moderate grade may 
or may not develop, depending largely upon the character of the 
tonsillar inflammation. When present the increase involves prin- 
cipally the polynuclear neutrophiles, and the total leucocyte count 
rarely exceeds 15,000 cells to the cubic millimeter. In simple 

1 Dermatolog. Zeitschr., 1897, vol. iv., p. 669. 
2 Loc. cit. 



TRICHINIASIS. 435 

catarrhal tonsillitis the count is usually normal, but leucocytosis is 
common in follicular tonsillitis and in quinsy. In the latter Pee, 1 
Rieder, 2 and others have observed leucocytosis in excess of 20,000. 

LXI. TRICHINIASIS. 

It is generally agreed that there are no changes 
Hemoglobin in the hemoglobin and erythrocytes attributable 
and to the influence of this infection, high counts and 
Erythrocytes, hemoglobin estimates, often polycythemia, being 
the rule. Rarely, well-marked anemia may be 
found, due to some other cause, as in a case reported by Kerr, 3 in 
which the erythrocytes numbered between 3,300,000 and 3,340,- 
000 per cubic millimeter. 

T. R. Brown 4 first made the important announce- 
Leucocytes. ment that acute cases of trichiniasis are accom- 
panied by a well-marked increase in the number 
of leucocytes, characterized by an absolute and relative gain in 
the eosinophils. This observation has since been corroborated 
by a number of other workers, whose results are tabulated below. 

Unfortunately, eosinophilia can not be regarded as constant in 
this condition, as shown by the following count made by the writer 
in a typical case of trichiniasis occurring in J. Chalmers DaCosta's 
surgical service at St. Joseph's Hospital : 

Hemoglobin, 80 per cent. 
Erythrocytes, 4,400,000 per cb. mm. 



Leucocytes, 12,000 " " " 

Small lymphocytes 36. 7 per cent. 

Large lymphocytes and transitional forms 6. 5 " 

Polynuclear neutrophiles 56.1 " 

Eosinophiles 0.5 " 

Myelocytes 0.2 " 

Basophiles 0.0 " 



Repeated examinations by others showed practically these 
figures, the eosinophiles at no time being increased. The lesions 
in this patient were most striking, as they involved the greater 
part of the right lower extremity, from calf to thigh. Excised 
bits of muscles from the affected parts were found to be swarm- 
ing with trichinae, and rich in eosinophile cells. It is possible 

1 Inaug. Dissert., Berlin, 1890. 
2 Loc. cit. 

3 Phila. Med. Journ., 1900, vol. vi., p. 346. 

4 Johns Hopkins Hosp. Bull., 1897, vol. iii., p. 79. Also, Journ. of Exper. Med., 
1898, vol. iii., p. 315. 



436 



GENERAL HEMATOLOGY. 



that in such instances as this, the absence of eosinophilia may be 
attributed to the overwhelming nature of the toxines, which, by 
their repellant action, stifle eosinophile proliferation in the marrow. 
Howard 1 also failed to find an eosinophile increase in a single 
case, although large numbers of these cells were detected in the 
muscle lesions. The report of the blood examination in Howard's 
case is so meagre (" Coverslip preparations of the blood stained 
with Ehrlich's triacid stain on examination showed a slight leuco- 
cytosis but no increase in the number of the eosinophilic cells") 
that it must be omitted from the following list of 18 cases reported 
since 1897. 



Name of Reporter. 


No. of Cases. 


Total Number of Leuco- 
cytes per cb. mm. 


Relative Percentage of 
Eosinophiles to other Forms 
of Leucocytes. 


T. R. Brown. 2 


3 


8,000-35,000 


8-68.2 


Gwyn. 3 
Kerr. 4 


1 

2 


I7,000 
10,000-25,000 


33-65-9 
18.1-86.6 


Blumer & Neuman. 5 


9 


6,000-24,000 


8-50.4 


Stump. 6 






52 


Cabot. 7 


1 


7,000-II ,000 


17-28 


Atkinson. 8 


1 


28,000 


35-58.5 



The other differential changes, which are unimportant, consist 
in a corresponding relative decrease in the polynuclear neutro- 
philes, and, occasionally, in the early stages of some cases, in a 
similar diminution in the lymphocytes. Mast cells, in the propor- 
tions of 1 or 2 per cent., have also been observed, although not 
constantly. 

Blumer and Neuman' s studies of 9 cases of epidemic trichini- 
asis, 9 lead them to conclude that the degree of leucocyte increase 
corresponds in a general way to the severity of the attack, rela- 
tively severe cases being attended with a higher and more per- 
sistent increase than the milder attacks ; on the other hand, the 
intensity of the infection does not necessarily correspond to the 
degree of eosinophilia. The latter may persist for months after 
the disappearance of the leucocytosis and the apparent convales- 
cence of the patient, but just how long it does last is as yet un- 
determined. 

1 Phila. Med. Journ., 1899, vol. iv., p. 1085. 
2 Loc. cit. 

3 Centralbl. f. Bakt. u. Parasit., 1899, vol. xxv., p. 746. 

4 Loc. cit. 

5 Am. Journ. of Med. Sc., 1900, vol. cxix., p. 14. 
6 Phi,la. Med. Journ., 1899, vol. iii., p. 1318. 

7 Boston Med. and Surg. Journ., 1897, vol. exxxvii., p. 676. 
8 Phila. Med. Journ., 1899, vol. iii., p. 1243. 
9 Loc. cit. 



TUBERCULOSIS. 



437 



The presence of an eosinophile leucocytosis, 
Diagnosis, usually of a high grade, may be the only indica- 
tion of trichiniasis in obscure cases in which the 
characteristic symptoms of the infection are wanting, and in such 
instances the change is to be regarded as a most valuable aid to 
diagnosis. Absence of this sign, however, does not definitely ex- 
clude the disease. 

LXII. TUBERCULOSIS. 

A pure infection with Koch's bacillus of tuber- 
General culosis is capable of producing comparatively 
Features, slight alteration in the composition of the blood, 
such changes as may be associated with tuber- 
culous processes, whatever organs they involve, being due chiefly 
to secondary infection with other bacteria, usually of pyogenic 
type, and not to the disease, per se. The prolonged ill effects of 
tuberculosis upon bodily nutrition must also in time cause more 
or less blood impoverishment, but it is a well-recognized clinical 
fact that the changes are as a rule trivial in comparison with the 
gravity of the disease, and the apparent degree of cachexia. The 
above facts are sufficient to explain the reason for the varied 
blood-pictures found in tuberculosis — pictures ranging from those 
of practically normal blood to those of most intense anemia, and 
from leucopenia to frank leucocytosis. 

In a limited number of cases of acute miliary 
Bacteriology, tuberculosis the specific bacillus has been isolated 
from the blood during life by culturing, but in 
this, as well as in the other forms of the disease, this procedure 
generally results negatively so far as the detection of the tubercle 
bacillus is concerned. In advanced septic cases of pulmonary 
tuberculosis, streptococci, staphylococci, and other micro-organ- 
isms have been found in the blood, but only rarely, for the septic 
process tends to remain localized in the lungs, rather than to in- 
vade the general circulation. 

Serum Test. Arloing and Courmont 1 have succeeded in pre- 
paring cultures with which they claim that the serum diagnosis 
of tuberculosis can be carried out. Glycerine peptone bouil- 
lon inoculated with an old, attenuated culture of the tubercle 
bacillus and thoroughly agitated each day to insure homoge- 
neity of the culture, finally develops a growth in which the 
bacilli are uniformly disseminated and actively motile. Blood 
serum from the suspected case is mixed in small test-tubes 
with the culture thus prepared, in proportions of I to 5, I 

1 Congres pour 1' Etude de la Tuberculose, 1898. 



438 



GENERAL HEMATOLOGY. 



to 10, and I to 20, and the tubes inclined at an angle of forty- 
five degrees, being examined at intervals of two, ten, and 
twenty-four hours. A positive reaction is indicated by a clarifica- 
tion of the mixture and the deposition of small flakes or granules 
in the bottom of the tube, while microscopically it may be seen 
that the bacilli are clumped and motionless. Reactions occurring 
after the lapse of twenty-four hours are without clinical signifi- 
cance. With normal serum in a dilution of 1 to 5 positive re- 
actions do not occur, and they occur but rarely with tuberculous 
serum in a dilution higher than 1 to 20. A peculiarity about 
this test is that it takes place in an inverse ratio to the intensity 
of the infection, and hence fails in advanced and virulent cases in 
which presumably there is already an excessive auto-intoxication 
with tuberculin. Excluding such cases, Arloing and Courmont 
found that positive reactions were constant in all tuberculous 
patients, but, unfortunately, they also found similar results in 
some normal individuals and in various non-tuberculous diseases. 

Bendix 1 found the test successful in 34 of 36 cases of tubercu- 
losis, the 2 failures being in instances of overwhelming infections ; 
he also claims that normal blood and the blood from other dis- 
eases gives negative results. Nine cases of pulmonary tubercu- 
losis, 4 of pleurisy, and 1 7 of various non-tuberculous affections 
were examined by Mongour and Buard. 2 All the phthisis cases, 
and 3 of the 4 pleurisies, which were tuberculous, were positive, 
the case not reacting proving to be non-tuberculous. In 1 5 of 17 
other diseases, the results of the test corresponded with the 
clinical diagnosis and the autopsy findings. Similar results in 
tuberculous pleurisy were obtained by P. Courmont, 3 who found 
positive reactions in 10 of 11 cases clinically tuberculous, while 
of 9 cases clinically non-tuberculous, 4 were positive and 5 nega- 
tive. In 1 2 cases of ascites, 7 due to hepatic cirrhosis failed to 
react, but the other 5, all clinically tuberculous, gave positive re- 
sults. Results distinctly less favorable than those reported by 
other investigators are published by Beck and Rabinowitch, 4 but 
it is not at all improbable that these discrepancies may be attrib- 
uted, at least in part, to the use of unsuitable cultures. Ac- 
cording to these authors' experiments, only 6 of 17 cases of in- 
cipient lung tuberculosis were positive, and but 4 of 16 advanced 
cases. Of 5 suspected cases that reacted to tuberculin injections, 

1 Deut. med. Woch., 1900, vol. xxvi., p. 224. 

2 Compt. rend. Soc. biol., Paris, 1898, 10 s., vol. v., p. 1142. Also, Buard: Journ. 
de phys. et path, gen., 1900, vol. ii., p. 797. 

;) Congres pour 1' Etude de la Tuberculose, 1898. 
4 Deut. med. Woch., 1900, vol. xxvi., p. 400. 



TUBERCULOSIS. 



439 



but a single one gave a positive serum reaction. They further- 
more found that positive reactions may occur in healthy persons, 
and in rheumatic fever, bronchitis, hepatic cirrhosis, and croupous 
pneumonia. Romberg 1 has determined that the serum of more 
than 50 per cent, of persons who fail to show clinical evidences 
of tuberculosis possesses a more or less agglutinative property. 

The serum reaction in tuberculosis, as at present elaborated, 
must be considered of questionable diagnostic value, since it has 
been shown that it may occur in normal individuals and in non- 
tuberculous diseases, and that it may often be negative in affec- 
tions undoubtedly tuberculous. As compared with Widal's 
typhoid reaction, the test of Arloing and Courmont is crude and 
untrustworthy. 

The change most frequently observed is a mod- 
Hemoglobix erate loss of hemoglobin, with little or no decrease 
and in the number of erythrocytes, and a low color 
Erythrocytes, index, resembling somewhat the blood-picture of 
chlorosis. In such instances poorly colored, small 
sized corpuscles may be numerous, but poikilocytes and other 
structural alterations in the cells are absent. In cases in which 
the effects of a complicating septicemic process are active, the 
above changes may be aggravated, and a secondary anemia of 
variable intensity is thus developed. The oligocythemia becomes 
marked and more proportionate to the oligochromemia, the color 
index consequently rising ; deformities of shape and size, and 
degenerative stroma changes become evident ; and in severe cases 
an occasional normoblast may stray into the circulation, especially 
after the occurrence of a hemorrhage. But these qualitative 
changes, even in advanced cases with marked cachexia, are com- 
paratively uncommon, and, when present, are usually not striking, 
in spite of the gravity of the disease. Finally, in a large propor- 
tion of tuberculous patients neither the hemoglobin nor the ery- 
throcytes fall below the normal standard, this being the rule both 
in incipient cases, and in those which, although of greater chron- 
icity, have escaped mixed infection, or have successfully withstood 
the ill effects of the constitutional drain. 

In 25 hospital cases of pulmonary tuberculosis in various stages, 
the writer found the hemoglobin percentage from 20 to 30 in 1 ; 
from 30 to 40 in 4, from 40 to 50 in 4; from 50 to 60 in 5 ; 
from 60 to 70 in 4; from 70 to 80 in 6, and from So to 90 in 1. 
The lowest estimate was 20, and the highest 83 per cent. The 
erythrocytes were in excess of 5,000,000 in 3 cases; from 4,000,- 

1 Deut. med. Woch., 1901, vol. xxvii., p. 292. 



44Q 



GENERAL HEMATOLOGY. 



ooo to 5,000,000 in 10; from 3,000,000 to 4,000,000 in 11, and 
from 2,000,000 to 3,000,000 in 1. The minimum count was 
2,660,000, and the maximum 5,500,000 cells per cubic millimeter. 

From a study of 43 cases of coxalgia, vertebral tuberculosis, 
and tuberculous osteomyelitis, Dane 1 concludes that most cases of 
tuberculous disease of the bones and joints do not cause a de- 
crease in the number of erythrocytes, although they do, however, 
affect the percentage of hemoglobin, giving rise to a mild degree 
of " chloro-anemia," so-called. An analysis of his series shows 
that the hemoglobin percentage ranged from 80 to 90 in 2 cases ; 
from 70 to 80 in 11 ; from 60 to 70 in 24 ; from 50 to 60 in 4 ; 
and from 40 to 50 in 2. The erythrocytes numbered 5,000,000 
or more in 24 cases, ranging between 6,000,000 and 7,000,000 
plus in 6; from 4,000,000 to 5,000,000 in 15 ; from 3,000,000 
to 4,000,000 in 3; and from 2,000,000 to 3,000,000 in 1. Ac- 
cording to P. K. Brown's investigations of 73 cases of bone 
tuberculosis, 2 the erythrocytes decrease only in long-continued 
and extensive cases, in very young children, and in secondary 
septic infections, while the hemoglobin is diminished practically 
in all cases, the loss depending upon the same factors which in- 
fluence the erythrocytes. He also observed that the patient's 
return to health is indicated by a tendency of the blood to re- 
turn to the normal standard. In about 15 per cent, of this 
author's cases there was an erythrocyte loss of one million or 
more cells per cubic millimeter, and in all but some half-dozen the 
hemoglobin was diminished, in one case to as low as 1 5 per cent. 

In cases with secondary septic infection the anemia disappears 
as the patient's recuperative powers become active, but should the 
latter be overwhelmed by the intensity of the pyogenic process, 
the anemia either remains stationary or grows more marked. 

In other forms of the disease — tuberculous adenitis, meningitis, 
pericarditis, pleurisy, peritonitis, and lesions of the genito-urinary 
system — the changes affecting the erythrocytes and their hemo- 
globin content do not differ from those already described. Well- 
developed secondary anemia is not uncommon in the two last- 
named forms of tuberculosis, while in the glandular variety dis- 
proportionately low hemoglobin values are frequently found. It 
is to be recalled that apparent polycythemia may be encountered 
in both tuberculous peritonitis and pleurisy, due in the former in- 
stance to the inspissating effect of the purging, and in the latter 
to the same effect produced by the sudden accumulation of an 
extensive exudate. 

1 Boston Med. and Surg. Journ., 1896, vol. cxxxiv., pp. 529, 559, and 589. 

2 Trans. Med. Soc. of State of California, 1 897, vol. xxvii., p. 168. 



TUBERCULOSIS. 



441 



Much the same factors which influence the 
Leucocytes, erythrocytes also determine the behavior of the 
leucocytes in the different forms of tuberculo- 
sis. In cases of unmixed infection these cells do not rise above 
the normal limits of health, but the moment the tuberculous 
lesion becomes complicated by a secondary infectious process, 
such, for instance, as septicemia, the accident is heralded by a 
prompt increase in their number. For example, in a simple 
tuberculous adenitis the count is normal, but should the glands 
ulcerate, fistulate, and become septic, a leucocytosis at once de- 
velops. As a rule, the qualitative changes are inconspicuous, 
although in some forms of the disease, as will be shown below, 
there is a tendency toward lymphocytosis. Increase in the 
number of leucocytes, characterized by a relative gain in the 
lymphocytes and eosinophiles, usually develops during the reac- 
tionary fever following the injection of tuberculin. 

The theory that the occurrence of Neusser's "perinuclear 
basophilic granules " during the course of the disease constitutes a 
favorable prognostic sign, has been effectually exploded, since 
later research has proved that these so-called granules are simply 
artefacts. (See page 176.) Iodinophile cells are generally found 
in septic cases, but they are absent in pure tuberculosis. 

In pulmonary tuberculosis leucocytosis may be symptomatic 
either of cavities or of rapidly spreading broncho-pneumonia, and 
it also usually follows hemorrhage of any considerable extent. 
No definite relationship apparently exists between the degree of 
pyrexia and the leucocyte count. Incipient cases of simple tu- 
berculous infiltration and pure lung cirrhosis are not accompanied 
by an increase. Of the 25 cases above referred to, about one- 
half showed a moderate leucocytosis, in 12 the count being 
10,000 or higher; in 6 between 9,000 and 10,000 ; in 2 between 
8,000 and 9,000 ; and in 2 between 3,000 and 8,000 per cubic 
millimeter. The highest estimate was 22,000, and the lowest 
3,152. Differential counts in 1 1 of the cases having an increase 
of 10,000 or more revealed no qualitative changes other than 
those typical of an ordinary polynuclear neutrophile leucocytosis. 
It may be added that in 6 of these 1 1 counts the eosinophiles 
were entirely absent. Myelocytes, in fractions of one per cent., 
were found in cases with high-grade anemia. 

A. M. Holmes 1 believes that it is possible to estimate not only 
the degree of the tuberculous process but the degree of the in- 
dividual's recuperative powers, by a careful study of the leuco- 

1 Second Pan- Am. Med. Cong., City of Mexico, Nov. 17, 1896. Also, Journ. 
Am. Med. Assn., 1897, vol. xxix., p. 828. 



442 



GENERAL HEMATOLOGY. 



cytes, using a special technique of staining with acid and basic 
dyes. Briefly, he considers that the pretuberculous stage is 
characterized by an absence of leucocytosis, a slight decrease in 
the lymphocytes, little or no increase in the polynuclear neutro- 
philes, more or less abundant debris from cell disintegration, and 
feeble differentiating powers of the cells. In the stage of early 
incipiency he finds that there may or may not be leucocytosis, 
accompanied by a gain in the polynuclear neutrophiles at the ex- 
pense of the lymphocytes as the disease advances, together with 
well-marked signs of cell disintegration and impaired differentia- 
tion. In the advanced stage, with cavity formation and extensive 
distribution of the lesions through the lungs, the preceding signs 
are thought to be still more strongly emphasized, especially those 
relating to the quantity of debris derived from cells undergoing 
dissolution. While it is true that the above changes in the leu- 
cocytes may be found in many cases of pulmonary tuberculosis, 
they by no means occur in all, nor can they be regarded as char- 
acteristic of this disease. Any septic or purulent process may 
cause a similar polynuclear neutrophile increase, while the pres- 
ence of degenerating forms of cells is not at all uncommon in 
such conditions. 

The numerical variations in the leucocytes in coxalgia, Pott's 
disease, and other forms of joint and bone tuberculosis are well 
illustrated by the following analysis of the large number of 
counts made by Brown 1 and by Dane 1 in these conditions. 



Leucocytes per cb. mm. 


Brown's 122 Counts. 


Dane's 51 Counts. 


Above 30,000 




in 


I 


4 


From 20,000 


to 


30,000 " 


8 


12 


" 18,000 




20,000 " 
18,000 " 


4 


1 


" 16,000 




5 


2 


" 14,000 


< < 


16,000 " 


16 


4 


" 12,000 


«« 


14,000 " 


22 


12 


" 10,000 




12,000 " 


18 


7 


" 9,000 


i t 


10,000 " 


19 


3 


8,000 


1 1 


9,000 ' ' 


9 


1 


" 7,000 


<< 


8,000 " 


8 


1 


" 6,000 


<, < 


7,000 " 


8 


4 


" 5>ooo 


<< 


6,000 " 


4 


0 


Maximum : 






31,250 


4i,3 6 9 


Minimum : 






5,100 


6,063 



In the great majority of instances the high counts picture a 
polynuclear neutrophile leucocytosis, but this is not invariably 
the rule, since in an occasional case the gain depends chiefly 

1 Loc. cit. 



TUBERCULOSIS. 



443 



upon an increase in the lymphocytes. Low counts may also 
be characterized by a relative lymphocytosis, this change being 
most common and most marked in young children, and in the 
profoundly cachectic. 

From the results of the painstaking clinical studies made by 
the above-mentioned writers, it may be concluded that in these 
forms of bone tuberculosis high leucocyte counts generally sig- 
nify that an abscess either exists or impends, although, on the 
contrary, low counts do not necessarily preclude the presence of 
an abscess. High counts, especially those of rapid develop- 
ment, point to a secondaiy pyogenic infection, while slowly 
developing, moderate leucocytoses appear to be compatible with 
simply a sudden increase in the activity of the tuberculous proc- 
ess. In the presence of an abscess, low counts usually indicate 
a pure tuberculous pus collection. Cases in which, at the first 
operation, the pus was proved sterile, show an increased leuco- 
cyte count when the wound becomes infected with pyogenic bac- 
teria. In these post-operative leucocytoses due to secondary 
infection, the count persists very high for a few days, and then 
gradually falls unless the sepsis is so acute as to threaten life, in 
event of which it may still remain high until a crisis is reached. 
Should the pyogenic infection be so severe as to overcome the 
patient's resisting powers, the leucocytosis either fails to develop, 
or else disappears. As in pulmonary tuberculosis, the leuco- 
cyte count and the degree of pyrexia apparently stand in no 
parallelism. 

Absence of a leucocyte increase is the rule in uncomplicated 
acute miliary tuberculosis, tuberculous adenitis, pleurisy, peritonitis, 
and pericarditis, whereas in tuberculosis of the genito-urinary ap- 
paratus high counts are not uncommon, owing to the frequency 
of secondary infections in such lesions. In tuberculous menin- 
gitis the behavior of the leucocytes is not constant, although 
most authors report a well-defined typical leucocytosis, ranging 
between 15,000 and 30,000 cells to the cubic millimeter. 

The presence of a leucocytosis in a lesion ob- 

Diagnosis. viously tuberculous, whatever its seat, is usually 
to be translated as a sign of some complicating 
secondary infection, the chief exceptions to this general rule being 
those infrequent cases in which the sudden extension of a purely 
tuberculous bone disease may cause a moderate, progressive rise 
in the count. A positive iodine reaction also points to a mixed 
infection. In pulmonary tuberculosis, if the influences of broncho- 
pneumonia and hemorrhage can be ruled out, leucocytosis almost 
invariably indicates the presence of cavity formation, and in bone- 



444 



GENERAL HEMATOLOGY. 



tuberculosis, the superposition of a pyogenic process. In perito- 
neal, pleural, and pericardial effusions low counts suggest an un- 
mixed tuberculous affection, unless the leucopenic influences of a 
virulent infection are to be found. The diagnosis between acute 
miliary tuberculosis and enteric fever has been referred to under 
the latter disease. (See page 331.) Blood-cultures should be 
made in every case of doubtful miliary tuberculosis, for posi- 
tive results, although rare, are conclusive when present. The 
leucocyte count may be quite as high in tuberculous as it is in 
non-tuberc ulou s meningitis. 

LXIII. TYPHUS FEVER. 

Lewaschew 1 claims to have found in the ex- 
Parasitology. amination of the finger blood of a large number 
of typhus patients a micrococcus, occurring both 
singly and in pairs, which he characterizes as the " micrococcus 
exanthematicus," and regards as the pathological agent of infec- 
tion. A diplococcus has recently been isolated by Balfour and 
Porter, 2 from blood obtained by puncture of the thumb, in 36 out 
of 43 cases of typhus examined by these authors. In a large 
number of control cases, including measles, scarlet fever, and en- 
teric fever, the organism in question was uniformly absent, except 
in the last-named disease in which it was discovered in 40 of the 
46 cases studied. Cultures of this parasite when injected intrave- 
nously into rabbits produced a rapidly fatal septicemia in these 
animals. These investigations, while interesting as pathological 
studies, throw no definite light on the etiology of typhus fever. 

From the limited data at present available con- 
Hemoglobin cerning the blood in this disease, it appears that 
and at the beginning of the attack the amount of 
Erythrocytes, hemoglobin and the number of erythrocytes re- 
main unchanged, but that later a moderate degree 
of anemia appears, being most marked during the period of apy- 
rexia. s Tumas' careful studies 3 of two cases, in which altogether 
twenty-five examinations were made, showed a hemoglobin range 
of from 50 to 94 per cent., with from 3,450,000 to 5,360,000 
erythrocytes per cubic millimeter, the minimum figures for both 
being observed during the second week of the infection. The 
presence of structural degenerative changes and of erythroblasts 
has not been recorded. In the acutest forms of the disease hemo- 
globinemia has been noted. 

1 Vratch, 1894, ns. 2 and 3. Abstr. , Sajous' Annual, 1895, sec. H., p. 45. 

2 Edinburgh Med. Journ., 1899, vol. vi., p. 522. 

3 Deut. Arch. f. klin. Med., 1887, vol. xli., p. 323. 



VACCINATION. 



445 



Absence of ieucocytosis, with occasional counts 
Leucocytes, showing a decided leucopenia, is the rule, as in 
enteric fever, according to conclusions of the 
most careful investigators of this question. Even the coexis- 
tence of another infection, alone sufficient to give rise to Ieu- 
cocytosis, seems to have no effect in provoking an increase, 
as evidenced by one of Tumas' cases, complicated by diph- 
theria, in which the number of leucocytes never exceeded 9,600 
per cubic millimeter ; in his other case they once rose to 
17,000 after a profuse sweat, but with the exception of this in- 
stance the counts all ranged between 1,600 and 9,600. Ew- 
ing 1 found a maximum count of 9,000, in a study of four cases, 
two of. which were fatal. It has not yet been determined 
whether or not qualitative changes affecting the leucocytes oc- 
cur in this disease. 

In differentiating typhus fever from epidemic 
Diagnosis, cerebrospinal meningitis the presence of a frank 
Ieucocytosis should be regarded as highly symp- 
tomatic of the latter. The behavior of the leucocytes fails to be 
of service in distinguishing typhus from typhoid, since in neither 
of these infections are these cells increased in number; here, how- 
ever, the serum test usually proves of signal utility. Absence of 
Ieucocytosis is also associated with malignant measles, the early 
stages of which may remind one of typhus fever. 

LXIV. VACCINATION. 

Billings 2 who has recently investigated the effects of vacci- 
nation on the blood, finds that no changes are produced in the 
hemoglobin and erythrocytes by this procedure. Moderate, but 
definite Ieucocytosis, the counts averaging about 15,000 per 
cubic millimeter, is characteristic. The Ieucocytosis is of the 
inflammatory type, and reaches its maximum coincidentally with 
the height of maturation of the vaccine pustule, fading away 
as the latter desiccates. Sobotka 3 finds the same alterations, 
and has also observed a secondary Ieucocytosis, beginning 
about the tenth or twelfth day, and often persisting for as long 
as six days, the height of the count corresponding in a general 
way to the severity of the local lesion, and to the activity of the 
virus. 

»" Clinical Pathology of the Blood," Phila. and N. Y., 1901. 
2 Med. News, 1898, vol. lxxiii., p. 301. 
3 Zeitschr. f. Heilk., 1893, vol. xiv., p. 349. 



446 



GENERAL HEMATOLOGY. 



LXV. VALVULAR HEART DISEASE. 

In well-compensated valvular lesions of the 
Stage of heart, irrespective of their character, the blood 
Compensation, shows no deviation from its normal composition, 
for such lesions of themselves are incapable of 
giving rise to blood changes. If the latter are observed in cases 
of this kind they should be attributed to other factors, rather 
than to the heart disease. 

In cases associated with acute failure of com- 
Acute Rup- pensation, however, changes in the blood-picture, 
ture of the intensity of which runs parallel to the severity 
Compensation, of the circulatory disturbances, sooner or later be- 
come manifest. These changes, consisting in the 
production of a so-called serous plethora, depend chiefly upon a re- 
duction in blood pressure, in consequence of which the blood mass 
becomes diluted by transudation into the vessels of fluids from the 
surrounding lymph spaces. It is also highly probable that this 
surcharging of the blood mass with liquids is aggravated by the 
disturbances in the functions of the heart and kidneys whereby 
the elimination of the superfluous watery constituents of the blood 
is hindered. Oertel 1 remarks that it seems not unlikely that an- 
other factor in the production of this hydremia may be found in 
the increased consumption of liquids, which he has noted in many 
patients suffering from valvular disease. Examination of the 
blood at this stage of the disease shows that there is a diminution 
in the albuminoid constituents and in the specific gravity of the 
blood, that the percentage of hemoglobin falls, and that oligo- 
cythemia proportionate to the latter develops ; the leucocytes, un- 
like the erythrocytes, do not decrease, but their number remains 
within normal limits. The observer must be careful not to mis- 
take the blood-picture of hydremia for that of a true anemia, from 
which it is distinguishable only by taking into consideration other 
clinical signs and symptoms. 

In cases of chronic valvular disease with stasis, 
Effects of dyspnea, and cyanosis, a very different picture 
Stasis. from that just described presents itself. The 
hydremia gives way to a concentration of the 
blood mass, this change being due mainly to the increased outflow 
of plasma from the vessels into the neighboring tissues, and per- 
haps to the excessive loss of water especially through the lungs, 
as Grawitz 2 has suggested. Stengel 3 offers as an explanation of 

1 Deut. Archiv. f. klin. Med., 1892, vol xxxi., p. 293. 
2 Loc. cit. 

3 Proc. Path. Soc. of Phila., 1898, n. s., vol. i., p. 137. 



VARICELLA. 



447 



this inspissation of the blood two other factors : the lagging of 
the erythrocytes in the peripheral arterioles and venules, and the 
increase in the viscosity of the blood. At this period of valvular 
disease the specific gravity and the proportion of albuminoid 
principles of the blood rise, and high hemoglobin values with 
more or less decided polycythemia are found, the erythrocyte 
count commonly being in the neighborhood of 6,000,000 per 
cubic millimeter, or in some instances, notably those of congenital 
heart disease, as high as from 7,000,000 to 8,000,000. Such a 
polycythemia, it should be remembered, may be sufficient com- 
pletely to mask a coexisting anemia ; in fact, it must be admitted 
that no reliable data concerning the true condition of the blood 
are obtainable in valvular disease of the heart, except during the 
stage of perfect compensation. The behavior of the leucocytes is 
capricious : their number may be normal, or, on the other hand, 
a decided, but not an excessive, leucocytosis may be present. 
Should this be the case, the increase will be found to involve 
principally the polynuclear neutrophile cells at the expense of 
the other forms. 

Grawitz 1 has drawn attention to the fact that a form of stroma 
degeneration may frequently be met with under these circum- 
stances, being evidenced by the unnatural readiness with which 
the hemoglobin tends to become diffused in the plasma within a 
short time after the removal of the blood from the body. This, 
while it cannot be termed a true hemoglobinemia, at least appears 
to demonstrate that the stroma and its hemoglobin are less 
firmly combined than they are in perfectly normal blood. 

The efforts made by some authors to associate certain blood 
conditions with definite valvular lesions seem to the writer far- 
fetched. The changes just described are thought by some to be 
especially prone to occur in affections of the mitral segments, 
and other authors even go so far as to state that disease of these 
valves is more often associated with transient apparent anemia or 
with chronic polycythemia than lesions of the aortic valves, the 
blood in the latter conditions being usually normal, or but 
slightly impoverished. After all, the general disturbances de- 
pendent upon the lesion, and not the lesion per se account for the 
alterations of the normal blood-picture which have been observed 
in heart disease of this type. 

LXVI. VARICELLA. 

The only observation on record appears to be that of Engel, 2 
who found in a child of five years, at the height of the pustular 

1 Loc. cit. 

2 XV. Cong. f. inn. Med., 1897. 



448 



GENERAL HEMATOLOGY. 



stage, 67 per cent, of polynuclear neutrophiles, and an absence 
of eosinophiles. After the healing of most of the pustules, three 
days later, the percentage of polynuclears was 47, and that of the 
eosinophiles 16. Numerical estimates in this case are not recorded. 

LXVII. VARIOLA. 

During the first few days of the attack the fibrin 
General network is normal, but as the stage of pustular 
Features, eruption is reached, a decided hyperinosis develops. 

Streptococci have been found in the blood repeat- 
edly by Widal and Benzacon. 1 Pfeiffer 2 has attached specific prop- 
erties to apparently ameboid bodies which he discovered in small- 
pox patients' blood, and other amebae have been found under 
similar circumstances by Reed, 3 by Weber, 4 and others. None 
of these discoveries have elucidated the etiology of variola. 

Post-febrile anemia, first becoming apparent 
Hemoglobin when defervescence is established, is the rule in 
and the majority of cases, the decrease in hemoglobin 
Erythrocytes, and corpuscles being usually decided, and not 
infrequently excessive. This is especially true in 
hemorrhagic and confluent variola, in which conditions a loss of 
two or three million cells per cubic millimeter may occur with 
great rapidity. The loss of hemoglobin begins slightly earlier 
than that of the corpuscles, but later both elements are usually 
diminished proportionately. 

During the febrile period of the disease, the number of erythro- 
cytes is approximately normal, or even increased, in case the 
blood becomes concentrated by the influence of the temperature. 

Qualitative changes in the erythrocytes are not marked, except 
in cases with severe anemia, in which poikilocytosis and deform- 
ities of size may be noted. In such instances hemoglobinemia 
may also be detected occasionally. Regeneration of the blood 
is said to be exceedingly slow. 

From the studies of Halla and Brouardel, and 
Leucocytes, of Pick, quoted by von Limbeck, 5 it appears that 
the influence of a variolous infection does not of 
itself cause leucocytosis, a fact which is evident for the reason that 
during the height of the initial fever, in the early eruptive stage of 
even well-marked cases, increase in the number of leucocytes 
does not occur. But as pustulation begins, and secondary infec- 
tion with pyogenic micro-organisms occurs, an increase in the leu- 

1 Centralbl. f. allg. Path., 1896, vol. vii., p. 569. 
2 Handb. d. spec. Therap., 1894, vol. i. , p. 229. 
3 Journ. of Exper. Med., 1897, vol. ii., p. 515. 
*Centralbl. f. Bakt. u. Parasit., 1897, vol. xxi., p. 286. 
5 Loc. cit. 



YELLOW FEVER. 



449 



oocytes takes place, the leucocytosis as a rule increasing propor- 
tionately to the gravity of the infection. As in other infections, 
very mild and very virulent cases do not give rise to an increase. 
In the average case, such as that quoted by von Limbeck, 1 the 
leucocytes, normal at the beginning of the illness, number about 
11,000 or 12,000 per cubic millimeter by the time the eruption 
becomes pustular, the maximum count of these cells, about 20,000, 
being attained coincidentally with full maturation of the pustules. 
As desiccation progresses, the number of leucocytes gradually falls, 
the normal count again being reached during the end of the second 
or the beginning of the third week. Varioloid, unless associated 
with suppuration, does not cause leucocytosis. Most authors have 
found that the increase involves chiefly the polymorphous forms 
of leucocytes, and that the percentage of mononuclear cells is 
proportionately decreased. On the other hand, Courmont and 
Montagard 2 insist that in uncomplicated cases the increase in- 
volves the mononuclear forms ; even during the pustular stage, 
when abscesses or furunculosis coexisted, they found the gain 
mononuclear in type. In severe infections it is common to find 
small numbers of myelocytes. Weil 3 has also found these same 
changes, and lays special stress upon the occurrence of myelo- 
cytes as a diagnostic sign of this exanthem. 

The blood plaques are decreased in number during the period of 
fever, being sometimes absent from the blood at this stage of the 
disease. 

Unfortunately, the blood examination is of no 
Diagnosis, value in differentiating variola from a number of 
other diseases which may more or less closely 
resemble it. For example, the prepustular stage of the disease 
has been mistaken for measles, but in both there is an absence of 
leucocytosis ; again, the pustular stage of small-pox may be 
counterfeited by varicella, pustular sypliilide, and the purpuric 
form of cerebrospinal meningitis, and all of these conditions are 
accompanied by a well-marked leucocytosis. 

LXVIII. YELLOW FEVER. 

Slow coagulation and deficiency or even com- 
General plete absence of the fibrin network is common, 
Features, these peculiarities being observable often in the 
earliest stages of the disease, apparently beginning 
coincidentally with the introduction of the infecting principle. 

1 Loc. cit. 

2 Province med., 1900, vol. xv., p. 481. 
3 Sem. med., 1900, vol. xx., p. 222. 

29 



450 



GENERAL HEMATOLOGY. 



The identity of the specific cause of this disease is a current 
topic of heated controversy. Sanarelli's claim, 1 that his bacillus 
icteroides is to be found in the circulating blood of yellow fever 
patients during life, has been flatly contradicted by several investiga- 
tors, notably by Agramonte, 2 and by the members of the United 
States Yellow Fever Commission, 3 Reed, Carroll, Agramonte, and 
Lazear, whose several reports show an uniform failure to isolate 
Sanarelli's bacillus either by ante-mortem blood cultures, or by 
post-mortem examinations of the blood and organs. In passing, it 
may be of interest to add that Finlay's theory, 4 that yellow fever 
is transmitted by means of the mosquito's bite, has been con- 
firmed beyond question by the experiments of this Commission, 
which has identified the Stegomyia fasciata as the offending insect. 
Archinard and Wood 5 claim that in a study of 50 cases of yel- 
low fever, they obtained a positive serum reaction with the bacil- 
lus icteroides in about 75 per cent, of the tests. In low dilutions 
(1:5, for instance) they found that the blood of yellow fever 
patients also clumped cultures of the typhoid bacillus. 

Pothier's studies of 1 54 cases at the New 

Hemoglobin Orleans Isolation Hospital, in 1897, 6 show that a 
and more or less decided loss of hemoglobin com- 
Erythrocytes. monly occurs during the active stages of the in- 
fection, and that the normal percentage is slowly 
regained during and after convalescence ; during the febrile period 
the hemoglobin ranged from 50 to 90 per cent.* and during con- 
valescence from 64 to So per cent. He found that the erythro- 
cyte count never fell below 4,280,000 per cubic millimeter, and 
that even in a fatal case it might be normal. Sternberg 7 has also 
noted the absence of quantitative changes affecting the erythro- 
cytes in this disease, stating that " although there is no general 
destruction of the red corpuscles, it is probable that a consider- 
able number of these elements perish, for the serum contains free 
hemoglobin, which gives it a yellow color even as early as the 
third or fourth day." This hemoglobinemia is common in all 
cases, but especially so in fatal cases just before death. The re- 

1 Annal. de l'lnstitut Pasteur, 1897, vol. xi., p. 433. Also, British Med. Journ., 
1897, vol. ii., p. 7. Also, Med. Record, 1897, vol. lxii.,p. 117. 

2 Med. News, 1900, vol. Ixxvi., p. 249. 

3 Phila. Med. Journ., 1900, vol. vi., p. 790. Also, Journ. Am. Med. Assn., 
1 901, vol. xxxvi., p. 431. 

* Pan-Am. Med. Cong., Havana, Feb. 4, 1901. Also, Journ. Am. Med. Assn., 
1901, vol. xxxvi., p. 1040. 

5 New Orleans Med. & Surg. Journ., 1 898, vol. 1., p. 455. 

6 Journ. Am. Med. Assn., 1898, vol. xxx., p. 885. 

7 U. S. M. H. Service Report on the Etiology and Prevention of Yellow Fever, 
Washington, 1890. 



YELLOW FEVER. 



451 



suits of these investigations by Pothier and by Sternberg are con- 
tradictory to the views expressed by earlier writers, who have 
been accustomed to describe the cellular elements of the blood 
in yellow fever as profoundly altered. 

Decided degenerative changes in the erythrocytes have not been 
observed, although it has been asserted by Jones 1 that these 
cells " present under the microscope certain peculiar appearances 
which are referable to the action of certain extraneous excretory 
matters in the blood." A few nucleated cells of the normoblas- 
tic type are reported to have been found occasionally. 

The behavior of the leucocytes in yellow fever 
Leucocytes, is extremely variable, their number being sub- 
normal in some cases, and decidedly, but not 
strikingly, increased in others. In the series of Pothier, just 
quoted, the counts ranged between 4,660 and 20,000 per cubic 
millimeter. The increase, when present, involves chiefly the 
polynnclear neutrophils, the relative proportion of these cells 
usually being in excess of 85 or 90 per cent. Small numbers of 
myelocytes were found occasionally by Cabot 2 in differential 
counts of twelve films of yellow fever blood. 

Sternberg 3 has described certain relatively large, highly refrac- 
tive, spherical granules in the protoplasm of the leucocytes, 
which he is inclined to regard as an evidence of fatty degenera- 
tion of these cells ; these granules were especially abundant in 
severe cases, nearly every leucocyte containing some of them. 
They are not, however, peculiar to yellow fever, since they have 
been found in the blood of patients suffering from beri-beri, and 
even in the blood of normal individuals, residents of the tropics. 

If Sanarelli's claims stand the test of time, 
Diagnosis, blood culturing and the clump reaction should 
prove of the greatest value in differentiating this 
infection from those obscure forms of dengue of which it may be 
a faithful clinical counterfeit. The frequency of hemoglobinemia 
in yellow fever and its absence, so far as is known, in dengue, 
may also serve as a hint of some importance. In differentiating 
malarial fever, the examination of the blood for the malarial par- 
asite will usually give definite information, and the occasional 
presence of a well-developed polynuclear leucocytosis in yellow 
fever should not be forgotten. 

1 Journ. Am. Med. Assn., 1895, vol. xxiv., p. 403. 
2 Loc. cit. 
3 Loc. cit. 



INDEX OF SUBJECTS. 



A BSCESS, 295 
coagulation, 295 
color index, 295 
diagnosis, 297 
erythrocytes, 295 
fibrin, 295 
hemoglobin, 295 
iodin reaction, 295 
leucocytes, 296 
normoblasts, 296 
Absence of leucocytosis, 185 

in acute infections, 188 
in enteric fever, 328 
in influenza, 354 
in leprosy, 358 
in malarial fever, 382 
in Malta fever, 394 
in measles, 395 
in tuberculosis, 441 
significance of, 188 
Acetanilid poisoning, 416 
Acetone, test for, 110 
Acetonemia, 1 10 
Achalme's bacillus, 422 
Achroiocythemia, 121 
Achromacytes, 138 
Acid dyes, 59 

Acidity of blood in Asiatic cholera, 304 

in insolation, 356 
Acromegaly, 298 
Actinomycosis, 298 
Acute yellow atrophy of the liver, 298 
Addison's disease, 299 
Adenitis, 197, 443 
Ague cake, 274 
Alcohol and ether fixation, 62 

fixation, 62 

poisoning, 416 
Alcoholic neuritis, 402 
Alexines, 185 
Alkalimeter, Engel's, 77 
Alkalinity, 77, 95 

estimation of, 77 

in Asiatic cholera, 304 

in chlorosis, 210 

in diabetes mellitus, 309 

in erysipelas, 332 

in fever, 334 

in gout, 347 

in hemorrhagic diseases, 348 
in Hodgkin's disease, 267 



Alkalinity in icterus, 353 

in infantile enteric fever, 290 

in insolation, 356 

in lymphatic leukemia, 256 

in nephritis, 399 

in osteomalacia, 406 

in pernicious anemia, 220 

in rheumatism, 422 

in scurvy, 348 

in secondary anemia, 237 

in spleno-medullary leukemia, 247 
Altitude, effect on blood, 133 
Altmann's bioblastic theory, 158 
Ammonia poisoning, 416 
Amphophile granules, 157 
Amyloid disease, 392 
Amyl nitrite poisoning, 416 
Analysis, centrifugal, 72 
Anopheles, 360 
Anemia, 1 13 

bothriocephalus, 356 

brick-makers', 357 

classification of, 1 14 

following splenectomy, 272 

from ankylostomiasis, 357 

from gastric tubule atrophy, 343 

from helminthiasis, 356 

from threadworms, 356 

from thyroidization, 399 

in appendicitis, 300 

in gastric cancer, 386 

in hemorrhagic diseases, 349 

in malignant disease, 391 
endocarditis, 393 

in nephritis, 400 

in rheumatic fever, 422 

in sepsis, 429 

in tuberculosis, 439 

in variola, 448 

infantum pseudo-leukemica, 290 
miners', 357 
pathogenesis of,^H5 
pernicious, 2 18 
post-hemorrhagic, 239 
post-malarial, 381 
post-typhoid, 326 
primary, 115 
pseudo-, 113 
secondary, 236 
splenic, 231 
syphilitic, 432 



454 



INDEX OF SUBJECTS. 



Anemia toxic, 416 

tropical, 114 
Anemias of infancy and childhood, 279 

classification, 283 

frequency, 282 

gastro-intestinal, 289 

general characteristics, 283 

leukemia, 284 

mild, 287 

pernicious, 284 

post-typhoid, 289 

primary, 284 

rachitic, 288 

secondary, 287 

severe, 287 

splenic enlargement, 283 

syphilitic, 288 

tuberculous, 289 

von Jaksch's, 290 

with leucocytosis, 287 
Aneurism, 297 
Anhydremia, 106 
Aniline dyes, 59 
Ankylostomiasis anemia, 357 
Anthrax, 299 
Antipyrin poisoning, 416 
Antipyretics, effects on leucocytes, 414 

erythrocytes, 123 
Aortic lesions, 447 
Appendicitis, 300 

anemia, 300 

diagnosis, 302 

leucocytosis, 301 
Arloing and Courmont's reaction, 437 
Arsenic, effect on blood, 121 
Arseniuretted hydrogen poisoning, 416 
Arthritis, septic, 423 
Ascites, 351 

chylous, 335 

effect on blood, 351 
Asiatic cholera, 304 
Aspidium poisoning, 416 
Asthma, 305 

Atmospheric cold, effect on blood, 181 
Atrophic hepatic cirrhosis, 350 
Atypical erythroblasts, 146 
Axillary abscess, 296 

OACTERIEMIA, 11 1 

in infants, 292 
Bacteria found in the blood, 112 

in anthrax, 299 

in beri-beri, 402 

in bubonic plague, 306 

in cerebro- spinal meningitis, 398 

in cholelithiasis, 308 

in enteric fever, 317 

in glanders, 346 

in influenza, 354 

in leprosy, 358 



Bacteria found in malignant endocarditis, 
392 

in Malta fever, 394 

in measles, 395 

in nephritis, 399 

in pneumonia, 411 

in purpura, 348 

in relapsing fever, 419 

in rheumatism, 422 

in scarlet fever, 424 

in scurvy, 348 

in sepsis, 428 

in tuberculosis, 437 

in typhus fever, 444 

in variola, 448 

in yellow fever, 450 
Bactericidal action of blood, 185 
Bacteriological examination, 83 
Band's disease, 231 
Barlow's disease, 348 
Basedow's disease, 333 
Basic dyes, 59 
Basophile granules, 157 
Basophil es, 166 

in Addison's disease, 299 

in carcinoma, 389 

in lymphatic leukemia, 260 

in sarcoma, 391 

in spleno-medullary leukemia, 256 
Basophilia, 202 

granular, 147 

perinuclear, 176 
Baths, effect on blood, 1 81 
Benario's method of fixation, 62 
Biermer's disease, 218 
Bile in the blood, 110 

test for, 1 10 
Bioblastic theory, Altmann's, 158 
Blackwater fever, 383 
Blastomycetes in carcinoma, 385 
Bleeders, 21 

Blood, arterial and venous, 94 
at birth, 280 
carbonic acid, 94 
color, 94 

concentration, 149 
crisis, 143 
crystals, 1 19 
cultures, 83, 1 12 
dust, 151 
extractives, 94 
fats, 94 
fetal, 279 
filaria, 335 
gases, 94 

general composition, 93 
laked, 94 
lancet, 20 
odor, 95 
oxygen, 94 



INDEX OF SUBJECTS. 455 



Blood plaques, 150 

counting the, 7 I 
in bubonic plague, 308 
in chlorosis, 216 
in diabetes mellitus, 312 
in enteric fever, 33 1 
in erysipelas, 332 
in hemorrhagic diseases, 350 
in Hodgkin's disease, 269 
in lymphatic leukemia, 260 
in malarial fever, 384 
in measles, 395 
in pernicious anemia, 228 
in pneumonia, 415 
in post-hemorrhagic anemia, 241 
in scarlet fever, 426 
in secondary anemia, 239 
in spleno-medullary leukemia, 
256 

in splenic anemia, 233 
in variola, 449 
nature, 150 
normal number, 151 
pathological variations, 15 1 
plasma, 93 
proteids, 93 
quantity, 93 
quotient, 122 
reaction, 95 
regeneration, 241 

after splenectomy, 272 

after treatment with suprarenal 

extract, 299 
in anemias of children, 283 
in carcinoma, 386 
in diphtheria, 312 
in enteric fever, 327 
in malarial fever, 379 
in pernicious anemia, 221 
in post-hemorrhagic anemia, 241 
in scarlet fever, 425 
in variola, 448 
salts, 93 
serum, 93 
specific test for, 88 
spectra, 125 
viscosity, 95 
Bone marrow, 128 

in leucocytosis, 187 
Bordet's reaction, 88 
Bothriocephalus anemia, 356 
Brain, abscess, 402 
hemorrhage, 402 
tumor, 402 
Breast, carcinoma of, 388 
Bremer's test, 310 
Bromine poisoning, 416 
Bronchitis, 306 
Bubonic plague, 306 

Budding of protopl asm of lymphocytes, 259 



CACHEXIA, malarial, 383 
^ Capillary bronchitis, 306 
Carbon monoxide hemoglobin, 125 
spectrum of, 125 
test for, 126 
Carbuncle, 189 
Carcinoma, 384 

alkalinity, 385 

coagulation, 384 

color index, 386 

deformed erythrocytes, 387 

diagnosis, 391 

digestion leucocytosis, 388 

erythroblasts, 387 

erythrocytes, 385 

fibrin, 384 

gastric, 388 

hemoglobin, 385 

hepatic, 388 

leucocytes, 387 

mammary, 388 

metastases, 387 

polycythemia, 386 

protozoa, 385 

rectal, 388 

regeneration, 386 

renal, 387 

specific gravity, 385 

sugar, 385 

uterine, 388 
Castration, effect on blood, 201 
Catarrhal pneumonia, 306 
Cecum, malignant disease of, 303 
Cellular elements of blood, 93 

plethora, 105 
Centrifugal analysis, 73 
Cerebral abscess, 296 
Cerebro-spinal meningitis, 396 
Cervical abscess, 296 
Charcot-Leyden crystals in leukemia, 246 
Chemical fixation, 62 
Chemotaxis, 184 
Chicken-pox, 447 
Chloral poisoning, 416 
Chloro-anemia, 237 
Chlorosis, 209 

alkalinity, 210 

appearance of fresh blood, 209 
blood plaques, 216 
coagulation, 209 
color index, 210 
diagnosis, 216 
Egyptian, 357 
eosinophiles, 215 
erythroblasts, 213 
erythrocytes, 210 
florid a, 217 

granular basophilia, 213 
hemoglobin, 210 
heredity, 217 



456 INDEX OF 

Chlorosis, leucocytes, 214 
male, 217 
microcytosis, 213 
myelocytes, 215 
pallor of erythrocytes, 213 
poikilocytosis, 213 
polychromatophilia, 213 
polynuclear neutrophiles, 215 
relative lymphocytosis, 215 
sex, 217 

specific gravity, 209 

symptoms, 217 

syphilitic, 432 

transitional forms, 215 

volume of blood, 209 

without blood changes, 217 
Cholelithiasis, 308 
Cholemia, no 
Chorea, 405 

Chromic acid fixation, 62 

poisoning by, 416 
Chyluria, parasitic, 355 
Cirrhosis of the liver, 350 
Class' diplococcus, 434 
Coagulation, 100 

in abscess, 295 

in acromegaly, 298 

in carcinoma, 384 

in chlorosis, 209 

in cholelithiasis, 308 

in fever, 334 

in hemophilia, 349 

in Hodgkin's disease, 267 

in icterus, 353 

in infantile enteric fever, 290 

in lymphatic leukemia, 256 

in nephritis, 399 

in obstructive jaundice, 353 

in pernicious anemia, 219 

in pneumonia, 411 

in rheumatic fever, 421 

in sarcoma, 389 

in scarlet fever, 423 

in secondary anemia, 236 

in spleno-medullary leukemia, 247 

in yellow fever, 449 

time, estimation of, 79 
Coagulometer, Wright's, 80 
Color index, 122 

of the blood, 94 

in aniline poisoning, 95 
in carbon monoxide poisoning, 
95 

in chlorosis, 209 

in diabetes mellitus, 309 

in dyspnea, 95 

in Hodgkin's disease, 267 

in icterus, 353 

in lymphatic leukemia, 256 

in nitrobenzol poisoning, 95 



SUBJECTS. 

Color of the blood in pernicious anemia, 
218 

in hydrocyanic acid poisoning,95 
in potassium chlorate poisoning, 
95 

in secondary anemia, 236 
in splenic anemia, 231 
in spleno-medullary leukemia, 
246 

in sulphuretted hydrogen poison- 
ing, 95 
normal variations, 94 
pathological variations, 94 
Coma, diabetic, 309 
Concentration of the blood, 149 
Convulsions, 404 
Corpuscles, Eichhorst's, 137 
phantom, 138 
Ponfick's, 138 
Corrosive metals and minerals, poisoning 
by, 416 

Counting chamber, Thoma-Zeiss, 43 
Zappert, 44 

differential, 70 

the blood plaques, 71 

the erythrocytes, 45, 54, 55 

the leucocytes, 49, 53, 55 
Cover-glasses, cleaning the, 22 
Coxalgia, 440 
Crenation, 126 
Crisis, blood, 143 
Crystals, Charcot-Leyden, 24 

Teichmann's, 120 
Culex, 361 

Cultures, blood, 83, 112 
Cyanosis, effect on blood, 150 
Cyst, ovarian, 303 
Cystitis, 189 

D ALAND'S hematocrit, 73 
Dare' s hemoglobinometer, 36 
Degeneration, endoglobular, 138 
Delafield's hematoxylin, 69 
Delirium, 404 
Dementia, 403 
Dengue, 451 

Density and opacity of blood, 94 
Dermatitis herpetiformis, 200 
Diabetes mellitus, 309 

alkalinity, 309 

blood plaques, 312 

Bremer's test, 310 

diagnosis, 312 

erythrocytes, 311 

glycemia, 309 

hemoglobin, 31 1 

iodine reaction, 312 

leucocytes, 312 

lipacidemia, 309 

lipemia, 309 



INDEX OF SUBJECTS. 457 



Diabetes mellitus, specific gravity, 312 
Williamson's test, 309 

Diapedesis, 156 

Diaphragm, ocular, 50 

Differential counting, 70 

table of the anemias, 243 
of leukemia, etc. , 275 
of normoblasts and megalo- 

blasts, 145 
of the leucocytes, 172 
of the malarial parasites, 376 

Digestion leucocytosis, 179 

in diabetes mellitus, 312 
in gastric carcinoma, 388 
in gastric ulcer, 345 
in gastritis, 344 
in infants, 281 

Diluting fluids, 40 

Diphtheria, 312 
diagnosis, 316 

effects of antitoxin, 313, 314 

erythrocytes, 313 

hemoglobin, 312 

leucocytes, 313 
Disease, malignant, 384 

Addison's, 299 

Barlow's, 349 

Band's, 231 

Biermer's, 218 

Duhring's, 200 

Graves', 333 

Griesinger' s, 357 

Hodgkin's, 267 

Laennec's, 351 

Potts' , 440 

von Taksch's, 290 
Diseases, hemorrhagic, 348 
Drug eosinophilia, 201 

leucocytosis, 194 

lymphocytosis, 198 
Duodenal ulcer, 346 
Durham's hemocytometer, 52 
Dwarf myelocytes, 171 
Dyes, aniline, 59 
Dysentery, 316 

PCHINOCOCCUS, 392 
J - > Ectopic pregnancy, 303 
Eczema, 200 
Effusion, pericardial, 406 

peritoneal, 351 

pleural, 409 
Egyptian chlorosis, 357 
Ehrlich's hypothesis, 158 

triacid stain, 64 
Ehrlich-Weigert fluid, 86 
Eichhorst's corpuscles, 137 
Electricity, effect on blood, 181 
Elephantiasis Arabum, 335 
Emphysema, 305 



Empyema, 410 

of gall-bladder, 296 
Endocarditis, malignant, 392 
Endoglobular degeneration, 138 
Engel's alkalimeter, 77 
Enteralgia, 303 
Enteric fever, 317 

'bacteriology, 317 

diagnosis, 331 

erythrocytes, 326 

hemoglobin, 326 

leucocytes, 328 

serum test, 319 

spot cultures, 318 
Enteritis, 316 

Eosin and hematoxylin stain, 68 

and methylene-blue stain, 67 
Eosinophile granules, 157 
Eosinophiles, 165 

diminution in, after castration, 201 

after hemorrhage, 201 

during digestion, 201 

in acute febrile diseases, 201 

in carcinoma, 389 

in chlorosis, 215 

in diphtheria, 315 

in enteric fever, 330 

in erysipelas, 333 

in gastric ulcer, 346 

in Hodgkin's disease, 269 

in lymphatic leukemia, 260 

in malarial fever, 383 

in measles, 396 

in meningitis, 397 

in pernicious anemia, 228 

in pertussis, 409 

in pneumonia, 415 

in sarcoma, 390 

in varicella, 448 

terminal, 201 
Eosinophilia, 198 
after coitus, 199 
after splenectomy, 274 
definition, 198 
during menstruation, 199 
experimental, 201 
factors, 199 

in ankylostomiasis, 357 

in asthma, 306 

in diseases of the bones, 200 
of the sexual organs, 201 
of the sympathetic nervous sys- 
tem, 201 

in gonorrhea, 346 

in helminthiasis, 200 

in hemorrhagic effusions, 409 

in herpes zoster, 353 

in infancy, 199 

in osteosarcoma, 390 

in oxyuris vermicularis infection, 357 



458 INDEX OF 

Eosinophilia in rheumatic fever, 423 
in scarlet fever, 426 
in septicemia, 431 
in skin diseases, 200 
in spleno- medullary leukemia, 255 
in starvation, 201 
in syphilis, 434 
in splenic tumors, 200 
in tenia mediocanellata infection, 
357 

in trichiniasis, 435 

in the xanthin diathesis, 201 

physiological, 199 

post-febrile, 200 
Eosinophilic myelocytes, 168 
Epilepsy, 405 
Erysipelas, 332 
Erythroblasts, 141 

atypical forms, 146 

differential count of, 71 
Erythrocytes, 126 

after fasting, 132 

ameboid motility, 134 

appearance in fresh blood, 1 26 

atypical staining, 140 

averages in anemia, 148 

color, 126 

counting the, 45, 54, 55 
crenation, 126 

deformities of size and shape, 136 

destruction, 128 

development, 128 

endoglobular degeneration, 138 

granular basophilia, 147 

histological structure, 1 27 

hyperviscosity, 136 

influence of age and sex, 130 

of constitution and nutrition, 132 
of digestion, 133 
of fatigue, 132 
of high altitudes, 1 33 
of physical factors, 130 
of pregnancy, menstruation and 
lactation, 131 

isotonicity, 135 

methods of counting, 40 

monochromatophilia, 140 

necrosis, 139 

normal number, 129 

nucleation, 14 1 

origin and life history, 128 

oval-shaped, 138 

pathological changes, 134 

physiological changes, 130 

polychromatophilia, 140 

rouleaux formation, 126 

size, 129 

stroma, 127 

volume, 130 
Erythrocytometer, 42 



SUBJECTS. 

Erythropyknosis, 372 
Estimation of alkalinity, 77 
of coagulation time, 79 

glass slide method/ 80 
Wright's method, 80 
of specific gravity, 75 
Ether leucocytosis, 193 

narcosis, 416 
Examination of the stained specimen, 58 

unstained specimen, 22 
Experimental eosinophilia, 201 

leucocytosis, 193 
Extractives of blood, 94 

"DAT in the blood, 106 

tests for, 107 
Fatty acids in the blood, no 

test for, 1 10 
Felon, 189 
Fetal blood, 279 
Fever, effect on blood, 333 

enteric, 317 

gastric, 343 

malarial, 359 

Malta, 394 

relapsing, 418 

rheumatic, 421 

scarlet, 423 

thermic, 355 

typhus, 444 

yellow, 449 
Fibrin, 100 

in abscess, 295 

in acromegaly, 298 

in carcinoma, 384 

in chlorosis, 209 

in cholelithiasis, 308 

in erysipelas, 332 

in fever, 334 

in gout, 347 

in influenza, 355 

in lymphatic leukemia, 256 

in measles, 395 

in nephritis, 399 

in pernicious anemia, 219 

in pneumonia, 41 1 

in rheumatic fever, 421 

in sarcoma, 389 

in scarlet fever, 423 

in sepsis, 427 

in spleno-medullary leukemia, 247 
in variola, 448 
in yellow fever, 449 
pathological variations, 102 
relation to leucocytosis, 103 
Filariasis, 334 

diagnosis, 342 
erythrocytes, 341 
filaria nocturna, 335 
hemoglobin, 341 



INDEX OF SUBJECTS. 



459 



Filariasis, leucocytes, 342 

occurrence, 334 

parasitology, 335 
Films, preparing the, 59 

staining the, 63 
Fixation methods, 61 

heat, 61 

chemical, 62 
Floating kidney, 303 
Fluids, diluting, 40 
Formalin fixation, 62 
Fractures, 343 

Fresh blood, microscopical examination 
of, 22 

Functional neuroses, 402 
Furuncle, 189 

GALL-STONE, 308 
Gangrene, 189 

appendicular, 301 
Garrod's thread test, 109 
Gastrectasis, 344 
Gases of blood, 94 
Gastric carcinoma, 386 
neurasthenia, 344 
tubules, atrophy of, 343 
ulcer, 345 
Gastritis, 343 
Gastro-enteritis, 316 
Genito-urinary tuberculosis, 440 
German measles, 396 
Glanders, 346 
Globulin, 119 
Glycemia, 108 

in diabetes mellitus, 309 
in carcinoma, 385 
Goldhorn's stain, 69 
Gonorrhea, 346 
Gout, 347 

Gower's hemocytometer, 54 
hemoglobinometer, 34 

Granular basophilia, 147 

in carcinoma, 387 
in lead poisoning, 417 
in malarial fever, 381 
in pernicious anemia, 226 
in secondary anemia, 238 
in spleno-medullary leukemia, 
250 

Granules, leucocyte, 157 
Graves' disease, 333 
Grippe, 354 

Guaiacol poisoning, 416 

Giinther's method of staining bacteria, 86 

HALITUS of blood, 95 
Hammerschlag's method, 75 
Hayem's achromacytes, 138 
pseudo-bacilli, 138 
solution, 41 



Heat exhaustion, 355 

fixation, 61 
Heart, chronic valvular disease, 446 

dilatation of, 406 

ulcerative endocarditis, 392 
Helminthiasis, intestinal, 356 
Helminthoma elastica, 342 
Hemameba leukemia?, 245 

malariae, 359 
Hematin, 119 
Hematocrit, Daland's, 73 
Hematoidin, 120 
Hematoporphyrin, 120 
Hemin, 120 
Hemochromogen, 119 
Hemoconia, 151 
Hemocytolysis, 1 15, 128 

in fever, 333 

in guaiacol poisoning, 416 

in insolation, 355 

in malarial fever, 380 

in pyrodin poisoning, 417 

in yellow fever, 450 
Hemocytometer, Durham's, 52 

Gower's, 54 

Oliver's, 56 

Thoma-Zeiss, 42 
Hemogenesis, 128 

adult, 143 

deficient, 115 

embryonal, 144 
Hemoglobin, 119 

absolute amount, 122 

after anesthesia, 416 

averages in anemia, 121 

chemistry of, 119 

estimation of, 25, 32, 34, 36, 39, 96 
in menstruation, 121 
influence of arsenic on, 121 

of iron on, 120 
origin, 120 
reduced, 119 

tests in surgical operations, 121 
Hemoglobinemia, 123 
from burns, 124 
from drugs, 123 
from exposures to cold, 124 
from heterogeneous blood, 124 
from mushroom poisoning, 124 
from snake and scorpion venom, 417 
in acute yellow atrophy of the liver, 
298 

in enteric fever, 124 

in epidemic hemoglobinuria, 124 

in insolation, 355 

in malarial fever, 380 

in paroxysmal hemoglobinuria, 124 

in Raynaud's disease, 124 

in scarlet fever, 424 

in scurvy, 124 



460 INDEX OF SUBJECTS. 



Hemoglobinemia in septicemia, 430 

in syphilis, 433 

in typhus fever, 444 

in variola, 448 

in yellow fever, 450 

spectrum of, 125 

test for, 124 
Hemoglobinometer, Dare's, 36 

Gowers', 34 

Oliver's, 32 

Tallquist's, 39 
Hemometer, von Fleischl's, 25 
Hemophilia, 348 

Hemophilics, danger of hemorrhage in, 

21 

Hemorrhage, effect on blood, 240 

regeneration after, 241 

treatment by saline transfusion, 241 
Hemorrhagic diseases, 348 
Hepatic abscess, 296 

carcinoma, 388 

cirrhosis, 350 

colic, 309 
Herpes zoster, 353 
Hewes's stain, 65 
Hodgkin's disease, 267 
alkalinity, 267 

appearance of fresh blood, 267 

basophiles, 269 

blood plaques, 269 

coagulation, 267 

color index, 267 

deformed erythrocytes, 267 

diagnosis, 269 

eosinophiles, 269 

erythroblasts, 267 

erythrocytes, 267 

hemoglobin, 267 

leucocytes, 268 

mast cells, 269 

myelocytes, 269 

polychromatophilia, 267 

relative lymphocytosis, 268 

specific gravity, 267 

symptoms, 270 
Hydremia, 105 
in fever, 334 
in nephritis, 399 
in valvular heart disease, 446 
Hydrocyanic acid poisoning, 417 
Hydrophobia, 417 
Hyperchlorhydria, 344 
Hyperinosis, 102 
Hyperleucocytosis, 185 
Hypertonicity, 135 
Hypertrophic hepatic cirrhosis, 351 
Hyperviscosity, 136 
Hypochlorhydria, 344 
Hypochondriasis, 402 
Hypoleucocytosis, 185 



Hypothesis, Ehrlich's, 158 
Hypotonia ty, 135 
Hypinosis, 102 
Hysteria, 402 

TCTERUS, 353 
1 Ileus, 357 

Illuminating gas poisoning, 192, 417 
Index, color, 122 

volume, 75, 130 
Infected wounds, 189 
Infection, latent, ill 
Influenza, 354 

Initial feeding, effect on blood, 281 

Insolation, 355 

Intestinal helminthiasis, 356 
inflammation, 316 
obstruction, 357 

Iodine poisoning, 417 

Iodine reaction, 174 

in abscess, 295 

in anemia, 175 

in diabetes mellitus, 312 

in pneumonia, 415 

in puerperal fever, 431 

in purpura hemorrhagica, I 

in septicemia, 431 

in septic tuberculosis, 441 

Iron, effect on hemoglobin, 120 
in blood, 119 
in eosinophiles, 158 

Irritants, effect on blood, 194 

Ischemia, 1 13 

Ischio-rectal abscess, 391 

Isotonicity, 135 

TOFFROY'S sign, 217 
J Jaundice, 353 
Jenner's stain, 65 
Justus' test, 433 

TZIDNEY, carcinoma of, 387 
Kra-kra, 335 

T ACTATION, effect on blood, 181 
^ Laennec's cirrhosis, 350 
Laked blood, 94 

Large mononuclear leucocytes, 1 61 

Latent infection, ill 

Lead poisoning, 417 

Leprosy, 358 

Leptomeningitis, 396 

Leucocytes, 155 

ameboid properties, 156 
appearance in fresh blood, 155 
classification, 159 
counting the, 49> 53> 55 
differential count of, 70 

table of, 172 
fatty degeneration, 451 



INDEX OF 

Leucocytes, fractured, 24 

granules, 157 

iodine reaction, 174 

methods of counting, 40 

normal percentages in adults, 159 
in children, 282 
number in adults, 159 
in children, 281 

origin and development, 173 

perinuclear basophilia, 176 

phagocytes, 156 

pigmented, 24, 355, 375, 420 

-size, 155 

vacuolated, 24 

varieties, 159 
Leucocytic phase, 186 
Leucocytolysis, 186 
Leucocytometer, 42 
Leucocytosis, 176 

after thymectomy, 196 

after splenectomy, 272 

average increase, 183 

definition, 176 

differential changes, 183 

digestion, 179 

drug, 194 

ether, 193 

experimental, 193 

factors, 178, 184 

from mechanical and thermal influ- 
ences, 181 
functions, 184 
general, 185 

in general infectious diseases, 189 
in malignant disease, 190 
in simple and infective local inflam- 
mations, 189 
inflammatory and infectious, 187 
influence of chemotaxis, 184 
leucocytic phase, 186 
leucopenic phase, 186 
local, 185 

marrow changes, 187 
of pregnancy and parturition, 180 
of the new-born, 178 
pathological, 182 
physiological, 177 
post-hemorrhagic, 191 
terminal, 181 
toxic, 192 
traumatic, 185 
Leucopenia, 203 

experimental, 206 
in chlorosis, 215 
in diphtheria, 314 
in enteric fever, 328 
in gastritis, 344 

in gastro- enteritis of infancy, 205 
in Hodgkin's disease, 269 
in malarial fever, 382 



SUBJECTS. 46 1 

Leucopenia in measles, 395 
in peritonitis, 408 
in pernicious anemia, 227 
in pneumonia, 414 
in sepsis, 431 
in splenic anemia, 233 
in tuberculous abscess, 443 
in typhus fever, 444 
pathological, 205 
physiological, 204 
Leucopenic phase, 186 
Leukemia, 244 
acute, 260 

blood picture, 261 

clinical features, 260 

duration, 261 

in children, 285 

statistics, 261 

transition from chronic forms, 
261 

frequency of different forms, 244 
in children, 284 

influence of intercurrent infections, 
261 

lymphatic, 256 

alkalinity, 256 

appearance of fresh blood, 256 
atypical lymphocytes, 259 
atypically stained erythrocytes, 
258 

basophiles, 260 

blood plaques, 260 

coagulation, 256 

color index, 257 

deformed erythrocytes, 258 

diagnosis, 264 

eosinophiles, 260 

erythroblasts, 257 

erythrocytes, 257 

hemoglobin, 257 

leucocytes, 258 

leukoblasts, 259 

lymphocytosis, 259 

lymphogonien, 259 

mast cells, 260 

myelocytes, 260 

polynuclear neutrophils, 260 

specific gravity, 256 
parasitology, 244 
spleno-medullary, 246 

alkalinity, 247 

appearance of fresh blood, 246 
atypical myelocytes, 253 

polynuclear neutrophiles, 
253 

basophiles, 256 
blood plaques, 256 
Charcot-Leyden crystals, 246 
coagulation, 247 
color index, 248 



462 



INDEX OF SUBJECTS. 



Leukemia, spleno-medullary, deformed 
erythrocytes, 250 
degenerate forms of leucocytes, 

.254 m 
diagnosis, 263 
dwarf myelocytes, 252 
eosinophilia, 255 
eosinophilic myelocytes, 255 
erythroblasts, 248 
erythrocytes, 247 
fibrin, 247 

fluctuations in hemoglobin and 
erythrocytes, 248 
in number of leucocytes, 25 1 
fractured leucocytes, 254 
granular basophilia, 250 
hemoglobin, 247 
influence of arsenic, 251 
karyokinesis, 250 
leucocytes, 250, 
lymphocytes, 255 
mast cells, 256 
megaloblasts, 249 
myelocytes, 252 
nuclear extrusion, 250 
polychromatophilia, 250 
polynu clear neutrophiles, 253 
predominance of normoblasts, 

249 _ 
pyknosis, 250 

relation of erythrocyte and leu- 
cocyte counts, 248 
remissions, 251 
specific gravity, 247 
stimulation forms, 255 
splenectomy in, 274 
transformation into pernicious ane- 
mia, 284 
transformations of type, 261 
Leukoblasts, 259 
Light-proof hemometer box, 30 
Lipacidemia, no 

in acute yellow atrophy of the liver, 
298 

in diabetes mellitus, 309 
Lipemia, 106 

in diabetes mellitus, 309 

in fractures, 343 
Liquor sanguinis, 93 
Liver, abcess, 296 

acute yellow atrophy, 298 

carcinoma, 388 

cirrhosis, 350 
Lowenthal's reaction, 420 
Ldwit's ameba, 245 
Lungs, malignant neoplasms of, 41 1 
Lupus, 200 
Lymph scrotum, 335 
Lymphangitis, 335 
Lymph emia, 261 



Lymphocytes, small, 160 

large, 161 
Lymphocytosis, 196 

absolute, 196 

after splenectomy, 274 

cachectic, 197 

definition, 196 

differential changes, 196 

drug, 198 

factors, 197 

in acromegaly, 298 

in acute infections, 197 

in Addison's disease, 299 

in adenitis, 197 

in carcinoma, 389 

in children, 282 

in chlorosis, 215 

in convulsions, 404 

in diphtheria, 315 

in enteric fever, 330 

in exophthalmic goitre, 333 

in filariasis, 342 

in gastritis, 344 

in gastro- enteritis, 289 

in Hodgkin's disease, 269 

in lymphatic leukemia, 259 

in malarial fever, 383 

in malignant disease, 389, 390 

in Malta fever, 394 

in measles, 396 

in meningitis, 397 

in osteomalacia, 406 

in pernicious anemia, 227 

in pertussis, 409 

in pneumonia, 415 

in purpura, 350 

in rachitis, 289 

in sarcoma, 390 

in scarlet fever, 426 

in scurvy, 350 

in secondary anemia, 197 

in splenic anemia, 238 
tumors, 197 

in syphilis, 434 

in thyroid tumors, 198 

in tuberculosis, 441 

in variola, 449 

of infancy, 197 

post -hemorrhagic, 192 

relative, 196 

terminal, 197 
Lymphogonien, 259 

MACROCYTES, 136 
Making the puncture, 19 
Malarial cachexia, 383 
fever, 359 

anemia, 381 
blood plaques, 384 
diagnosis, 384 



INDEX OF 

Malarial fever, erythrocytes, 379 
hemoglobin, 379 
leucocytes, 382 
parasite, 359 

crescentic forms, 373 
degenerate forms, 367, 

370, 374 
development in man, 359 

in mosquito, 360 
disc forms, 371 
estivo-autumnal, 370 
flagellate forms, 366, 370, 
374 

infecdon with multiple 

groups, 361, 367 
intracellular hyaline forms, 

362, 368, 371 
ovoid bodies, 373 
pigmented extracellular 

forms, 365, 370,374 
intracellular forms, 

363, 368, 372 
leucocytes, 375 
quartan, 367 
ring forms, 371 
segmenting forms, 364, 

3 6 9, 372 
spherical bodies, 373 
tertian, 362 

vacuolized forms, 367, 370, 
375 

phagocytosis, 375 
technique of examination, 376 
spleen, 274 
Male chlorosis, 217 
Malignant disease, 384 

endocarditis, 392 
Malta fever, 394 
Mania, 403 

Maragliano's necrosis, 139 

Massage, effect on blood, 181 

Mast cell granules, 157 
cells, 168 

in Asiatic cholera, 305 
in carcinoma, 202 
in chlorosis, 202 
in filariasis, 342 
in gonorrhea, 202 
in lymphatic leukemia, 260 
in mycosis fungoides, 202 
in sepdc bone disease, 202 
in skin diseases, 202 
in splenic anemia, 233 
in spleno-medullary leukemia, 
256 

in trichiniasis, 436 
Masdtis, 189 
Masturbation, 403 
Measles, 395 

Megaloblastic blood-picture, 229 



SUBJECTS. 463 

Megaloblasts, 143 
Megalocytes, 136 
Melancholia, 403 
Melanemia, 107 

in Addison's disease, 299 

in insolation, 355 

in malarial fever, 375 

in relapsing fever, 420 
Meningitis, 396 

cerebro-spinal, 397 

tuberculous, 397 
Mental diseases, 402 
Mercury, effect on blood, 432 
Mesoblasts, 146 
Methemoglobin, 119 

spectrum of, 125 

tests for, 124 
Methemoglobinemia, 124 

from drugs, 124 

in Addison's disease, 299 

in poisoning, 416 

in purpura hemorrhagica, 348 
Methods, fixation, 61 

of examination, 19 

of staining, 63 
Microblasts, 145 
Microcytes, 137 

Microspectroscope, Sorby-Beck, 81 
Miculicz's dictum, 1 21 
Mitral lesions, 447 
Monochromatophilia, 140 
Mononuclear neutrophiles, 1 71 
Mosquito, development of filaria nocturna 
in, 337 
of malarial parasite in, 360 
yellow fever, 450 
Mucinoblasts, 170 
Multiple neuritis, 402 
Muscular exercise, effect on blood, 18 1 
Myelemia, 202 
Myelocytes, 167 

atypical forms in leukemia, 253 

dwarf, 171 

eosinophilic, 168 

in abscess, 297 

in Addison's disease, 299 

in anemia of children, 283 

infantum pseudo-leukemica, 290 

in carcinoma, 389 

in chlorosis, 215 

in convulsions, 404 

in diphtheria, 316 

in enteric fever, 331 

in erysipelas, 333 

in gastro- enteritis, 2S9 

in gout, 347 

in herpes zoster, 353 

in Hodgkin's disease, 269 

in infantile enteric fever, 289 
syphilis, 288 



464 INDEX OF 

Myelocytes in lymphatic leukemia, 260 

in malarial fever, 383 

in myxedema, 398 

in osteomalacia, 406 

in pernicious anemia, 228 

in post-hemorrhagic leucocytosis, 192 

in rachitis, 288 

in sarcoma, 391 

in scarlet fever, 426 

in secondary anemia, 238 

in splenic anemia, 233 

in spleno- medullary leukemia, 252 

in syphilis, 434 

in tuberculosis, 441 

in variola, 449 

in yellow fever, 451 
Myxedema, 398 

NECROSIS, Maragliano's, 139 
Needle for blood culturing, 84 
Negro lethargy, 335 
Nephritis, 399 
Nervous diseases, 402 
Neuralgia, 402 

ovarian, 304 
Neurasthenia, 402 
gastric, 344 
sexual, 403 
Neuritis, 402 
Neuroses, functional, 402 
Neutral dyes, 59 
Neutrophile granules, 1 57 
Neutrophiles, polynuclear, 163 

mononuclear, 171 
Neutrophilic pseudo-lymphocytes, 171 
Newton's rings, 47 
Nikiforoff 's method of fixation, 62 
Nitrobenzol poisoning, 417 
Nitroglycerine poisoning, 417 
Normoblasts, 141 
Nuclear stains, 59 
Nucleated erythrocytes, 141 
Nucleolation of lymphocytes, 260 

QBERMEIER'S spirillum, 418 
^ Obesity, 406 
Objects of staining, 58 
Obstruction, intestinal, 357 
Obstructive jaundice, coagulation in, 353 
Ocular diaphragm, 50 
Odor and viscosity of blood, 95 
Oligemia, 103 
Oligochromemia, 121 
Oligocythemia, 148 
Oliver's hemocytometer, 56 
hemoglobinometer, 32 
Opium poisoning, 417 
Osmic acid fixation, 63 
Osteomalacia, 406 
Osteomyelitis, 427 



SUBJECTS. 

Osteomyelitis, tuberculous, 440 
Osteosarcoma, 390 
Otitis media, 189 
Oval-shaped erythrocytes, 138 

in epidemic dropsy, 223 

in pernicious anemia, 223 

in purpura hemorrhagica, 223 
Ovarian abscess, 296 

cyst, 303 

Ovaritis, 189 
Oven for fixation, 61 
Oxyhemoglobin, 119 
spectrum of, 125 

PACHYMENINGITIS, 396 

Palmar abscess, 296 
Pancreatitis, 1 89 
Panoptic staining, 63 
Paresis, 403 

Pathological leucocytosis, 182 

leucopenia, 205 
Pellagra, 189 
Pelvic abscess, 296 
Pemphigus, 189 
Pericardial effusion, 406 
Perinuclear basophilia, 176 
Peritonitis, 407 

appendicular, 301 

hysterical, 408 

septic, 407 

serous, 407 

tuberculous, 440 
Periurethral abscess, 296 
Pernicious anemia, 218 
alkalinity, 220 

appearance of fresh blood, 218 
blood plaques, 228 
coagulation, 219 
color index, 220 
diagnosis, 228 
Eichhorst's corpuscles, 223 
eosinophiles, 228 
erythroblasts, 223 
erythrocytes, 220 
fibrin, 219 

fluctuations in number of eryth- 
rocytes, 225 
granular basophilia, 226 
hemoglobin, 220 
horseshoe-shaped cells, 223 
in children, 284 
isotonicity, 135 
leucocytes, 227 
megaloblasts, 224 
megalocytes, 223 
mesoblasts, 225 
microblasts, 225 
myelocytes, 228 
nuclear extrusion, 225 
oligemia, 218 



INDEX OF SUBJECTS. 



465 



Pernicious anemia, oval-shaped cells, 223 
phantom corpuscles, 219 
poikilocytosis, 223 
polychromatophilia, 225 
polynuclear neutrophiles, 227 
predominance of megaloblasts, 
224 

relative lymphocytosis, 227 
rouleaux formation, 219 
specific gravity, 219 
symptoms, 229 
syphilitic, 432 

transformation into leukemia, 
284 
Pertussis, 408 
Pfeiffer's phenomenon, 87 
Phagocytosis, 156, 185 

in malarial fever, 375 

in relapsing fever, 420 
Phantom corpuscles, 138 

tumor, 408 
Phlebitis, 189 
Phosphorus poisoning, 417 
Physiological leucocytosis, 177 

leucopenia, 204 
Pigmented leucocytes, in insolation, 355 
in malarial fever, 375 
in relapsing fever, 420 
Pipette, Durham's, 53 

Gower's, 35 

Oliver's, 32 

Thoma-Zeiss, 42 
Pinocytosis, 156 
Plague, bubonic, 306 
Plasma stains, 59 
Plasmodium malarise, 359 
Plethora, 104 

in obesity, 406 
Pleura, malignant neoplasms of, 41 1 
Pleurisy, serous, 409 

purulent, 410 
Plimmer' s bodies, 385 
Plumbic neuritis, 402 
Plumbism, acute, 417 
Pneumonia, 411 

artificial leucocytosis, 414 

bacteriology, 411 

blood plaques, 415 

diagnosis, 415 

effect of antipyretics and cold, 414 

erythrocytes, 412 

hemoglobin, 412 

hyperinosis, 41 1 

iodine reaction, 415 

leucocytes, 413 

lymphocytosis, 415 

serum test, 41 1 

specific gravity, 41 1 
Poisoning, 416 
Poikilocytes, 137 



Polychromatophilia, 140 
Polycythemia, 149 

after paracentesis, 351 
after transfusion, 242 
after urinary crises, 150 
after use of purgatives, 316 
during blood regeneration, 242 
digestion, 132 
menstruation, 131 
from administration of lymphogogues 

and emetics, 150 
from physiological causes, 149 
in acute yellow atrophy of the liver, 
298 

in Asiatic cholera, 304 
in asthma, 305 
in bubonic plague, 307 
in convulsions, 404 
in diarrhea, 316 
in dysentery, 316 
in emphysema, 305 
in fever, 333 

in gastric and esophageal cancer, 386 

carcinoma, 386 

ulcer, 345 
in gastritis, 343 
in icterus, 354 

in illuminating- gas poisoning, 417 
in insolation, 355 ' . 
in nephritis, 401 
in phosphorus poisoning, 417 
in pneumonia, 412 
in the new-born, 130 
in tuberculosis, 440 
in valvular heart disease, 447 
of high altitudes, 133 
Polyemia, 104 

Polynuclear neutrophiles, 163 
Post-hemorrhagic anemia, 239 

blood crises, 242 
plaques, 241 

color index, 242 

erythroblasts, 242 

erythrocytes, 240 

etiology, 239 

fatality, 240 

hemoglobin, 240 

hydropic erythrocytes, 242 

immediate effects of blood loss, 
240 

leucocytes, 240 
leucocytosis, 191 
lymphocytosis, 192 
microcytes, 242 
oligemia, 240 
polycythemia, 242 
polychromatophilia, 242 
rapidity of hemoglobin gain, 242 
regeneration, 241 
saline solution, effect of, 241 



30 



4 66 



INDEX OF SUBJECTS. 



Potts' disease, 440 
Ponfick's corpuscles, 138 
Pre-agonal leucocytosis, 181 
Pregnancy, 131 

ectopic, 303 
Preparing the films, 59 

the slide, 21 
Prince's stain, 66 
Protozoa in beri-beri, 402 

in carcinoma, 385 

in leukemia, 245 

in measles, 395 

in variola, 448 
Prurigo, 200 
Pseudo-anemia, 113 
Pseudo-bacilli, 138 
Pseudolymphocytes, neutrophilic, 171 
Psoriasis, 200 
Ptomaine poisoning, 417 
Puerperal fever, 430 
Purges, effects on blood, 316 
Purpura, 348 
Purulent lesions, 189 
Pyelonephritis, 189 
Pyemia, 427 
Pyknosis, 250 
Pyonephrosis, 303 
Pyosalpinx, 296 
Pyrodin poisoning, 417 
Pyrogallic acid poisoning, 417 
Pyrogallol poisoning, 417 

QUANTITY of blood, 93 
Quinsy, 435 
Quotient, blood, 122 

RABIES, 417 
Raspberry-jelly clots, 247 
Ratio of erythrocytes to leucocytes, 155 

of erythrocytes to plaques, 72 
Reaction, Arloing and Courmont's, 437 
Bordet's, 88 
Lowenthal's, 420 
Widal's, 86 

of blood, 95 

pathological variations, 97 

physiological variations, 96 
Rectum, carcinoma of, 388 
Reizungsformen, 1 71 
Relapsing fever, 418 

bacilli, 419 

diagnosis, 421 

diplococci, 419 

erythrocytes, 421 

hemoglobin, 421 

leucocytes, 421 

Lowenthal's reaction, 420 

melanin, 420 

parasitology, 418 

phagocytosis, 420 



Relapsing fever, pigmented leucocytes, 
420 

Remissions in pernicious anemia, 225 

in spleno-medullary leukemia, 251 
Renal abscess, 296 

colic, 309 
Revulsives, effect on blood, 194 
Rheumatism, chronic, 422 
Rheumatic fever, 421 

alkalinity, 421 

bacteriology, 422 

coagulation, 421 

color index, 422 

diagnosis, 423 

erythrocytes, 422 

fibrin, 421 

hemoglobin, 422 

leucocytes, 422 
Rollet, stroma of, 127 
Rotheln, 396 
Rouleaux formation, 126 
Rupture of the spleen, 274 
Russell's bodies, 385 

SALINE purges, effect on blood, 316 
Salts of blood, 93 
Sanarelli's bacillus, 450 
Sapremia, 427 
Sarcoma, 389 

coagulation, 389 
deformed erythrocytes, 390 
diagnosis, 391 
erythroblasts, 390 
erythrocytes, 389 
fibrin, 389 
hemoglobin, 389 
leucocytes, 390 
specific gravity, 389 
Scarlet fever, 423 

bacteriology, 424 
blood plaques, 426 
coagulation, 423 
diagnosis, 426 
erythrocytes, 424 
fibrin, 423 
hemoglobin, 424 
leucocytes, 425 
specific gravity, 423 
Scleroderma, 200 
Scorpion poisoning, 417 
Scrotum, lymph, 335 
Scurvy, 348 
Secondary anemia, 236 
alkalinity, 237 

appearance of fresh blood, 236 
average hemoglobin and eryth- 
rocyte losses, 238 
blood plaques, 239 
coagulation, 236 
color index, 237 



INDEX OF SUBJECTS. 467 



Secondary anemia, deformed erythrocytes, 
238 

diagnosis, 239 

eosinophils, 238 

erythroblasts, 238 

erythrocytes, 237 

granular basophilia, 238 

hemoglobin, 237 

leucocytes, 238 

myelocytes, 238 

pallor of erythrocytes, 238 

poikilocytosis, 238 

polychromatophilia, 238 

polynuclear neutrophiles, 238 

relative lymphocytosis, 238 

specific gravity, 236 
Septic arthritis, 427 
Septicemia and pyemia, 427 

bacteriology, 428 

color index, 430 

diagnosis, 431 

erythrocytes, 429 

fibrin, 427 

hemoglobin, 429 

leucocytes, 431 

serum reaction, 427 
Serous plethora, 104 
Serum reaction, determination of, 86 

in Asiatic cholera, 304 

in bubonic plague, 307 

in children, 290 

in colon infections, 427 

in enteric fever, 319 

in leprosy, 358 

in Malta fever, 394 

in pneumococcus infections, 427 

in pneumonia, 411 

in relapsing fever, 420 

in septicemia, 427 

in streptococcus infections, 427 

in tuberculosis, 437 

in yellow fever, 450 
Sexual neurasthenia, 403 
Shadow corpuscles, 138 
Sherrington's solution, 41 
Shingles, 353 
Sign, Joffroy's, 217 
Sleeping sickness, 335 
Slide, preparing the, 21 
Small lymphocytes, 160 
Small -pox, 448 
Sodium nitrite poisoning, 417 
Solution, Hayem's, 41 
isotonic, 135 

saline, after hemorrhage, 241 

Sherrington's, 41 

Toisson's, 41 
Sorby-Beck microspectroscope, 8i 
Sorby's tubular cell, 82 
Specific gravity, 98 



Specific gravity, estimation of, 75 
in Asiatic cholera, 304 
in carcinoma, 385 
in children, 280 
in chlorosis, 209 
in diabetes mellitus, 312 
in Hodgkin's disease, 267 
' in icterus, 353 

in lymphatic leukemia, 256 
in nephritis, 399 
in pernicious anemia, 219 
in pneumonia, 41 1 
in purpura hemorrhagica, 348 
in sarcoma, 389 
in scarlet fever, 423 
in secondary anemia, 236 
in spleno-medullary leukemia, 
247 

in the fetus, 279 

in the new-born, 280 

in valvular heart disease, 446 

normal range, 98 

pathological variations, 99 

relation to hemoglobin, 100 

table of hemoglobin equiva- 
lents, 101 
Spectra, blood, 125 
Spectroscopical examination, 81 
Spirillum of Obermeier, 418 
Splenectomy, 272 
Splenic anemia, 231 

appearance of fresh blood, 231 

blood plaques, 233 

color index, 232 

diagnosis, 233 

eosinophiles, 233 

erythroblasts, 232 

erythrocytes, 231 

hemoglobin, 231 

leucocytes, 233 

mast cells, 233 

megaloblasts, 232 

megalocytosis, 232 

myelocytes, 233 

poikilocytosis, 232 

polychromatophilia, 232 

polynuclear neutrophiles, 233 

relative lymphocytosis, 233 

symptoms, 234 
Splenitis, 189 
Splenolymph glands, 128 
Spot culturing, 318 
Snake poisoning, 417 
Stain, Ehrlich's triacid, 64 
Ehrlich-Weigert, 86 
eosin and hematoxylin, 68 

methylene-blue, 67 
Goldberger and Weiss', 174 
Hewes', 65 
Jenner's, 65 



468 INDEX OF SUBJECTS. 



Stain, Loffler's, 65 
Prince's, 66 

polychrome methylene-blue, 69 

thionin, 69 
Stained specimen, examination of the, 58 
Staining, methods of, 63 

double, 63 

objects of, 58 

panoptic, 63 

triple, 63 
Stasis, effect on blood, 446 
Stegomyia fasciata, 450 
Stimulation forms, 171 

in spleno-medullary leukemia, 
255 

in enteric fever, 331 

in erysipelas, 333 
Stomach, carcinoma of, 388 
Stroma of Rollet, 127 
Sugar in the blood, 108 

in carcinoma, 385 

in diabetes mellitus, 309 

test for, 108 
Sunstroke, 355 

Sweating, effects on blood, 150 
Syphilis, 432 

diagnosis, 434 

effect of mercury, 432 

erythrocytes, 432 

hemoglobin, 432 

Justus' test, 433 

leucocytes, 434 

^ALLQUIST'S hemoglobinometer, 39 

Tansy poisoning, 417 
Teichmann's crystals, 1 20 
Terminal leucocytosis, 181 
Test, Bordet's, 88 

Bremer's, 310 

for acetone, no 

for alkalinity, 77 

for bile, 1 10 

for carbon monoxide hemoglobin, 

126 
for fat, 107 
for fatty acids, no 
for glycogen, 174 
for hemin, 1 20 
for hemoglobin, 25 
for hemoglobinemia, 124 
for human blood, 88 
for methemoglobin, 124 
for sugar, 108 
for uric acid, 109 
Garrod's, 109 
Justus', 433 
Lowenthal's, 420 
Widal's, 86 
Williamson's, 309 
Tetanus, 434 



Tetany, 405 

Thionin stain, 69 

Thoma-Zeiss hemocytometer, 42 

Thymectomy, leucocytosis after, 196 

Toadstool poisoning, 417 

Toisson's solution, 41 

Toluene poisoning, 417 

Tonsillitis, 434 

Total necrosis, 139 

Toxic leucocytosis, 192 

Transitional forms, 162 

Triacid stain, 64 

Triboulet's diplococcus, 422 

Trichiniasis, 435 

Tropical anemia, 1 14 

Tuberculosis, 437 

bacteriology, 437 

diagnosis, 443 

erythrocytes, 439 

forms of anemia, 437 

genito-urinary, 440, 443 

glandular, 440, 443 

hemoglobin, 439 

hip-joint, 440, 442 

iodine reaction, 441 

leucocytes, 441 

meningeal, 397, 443 

osseous, 440, 442 

peritoneal, 440, 443 

pleural, 440, 443 

polycythemia, 440 

pulmonary, 439, 441 

secondary infections, 439, 441 

serum reaction, 437 
" ' vertebral, 440, 442 
Tuberculous meningitis, 397 
Tubular cell, Sorby's, 82 
Tumor, brain, 402 

phantom, 408 
Turpentine poisoning, 417 
Typhus fever, 444 

TTLCER, duodenal, 346 
U gastric, 345 
Uremia, 401 
Uric acid, in gout, 347 

test for, 109 
Uricacidemia, 109 
Urinary crises, effect on blood, 150 
Urticaria, 200 
Uskow's theory, 173 
Uterus, carcinoma of, 38S 

VACCINATION, 445 
* Valeur globulaire, 122 
Valvular heart disease, 446 
Varicella, 447 
Variola, 448 
Varioloid, 449 
Violet of Hoyer, 69 



INDEX OF SUBJECTS. 



Volume index, 75, 130 
Vomiting, effect on blood, 150 
Von Fleischl's hemometer, 25 
Von Jaksch's anemia, 290 

WANDERING spleen, 274 
Whooping-cough, 408 
Widal's test, 86 



Williamson's test, 309 
Wright's coagulometer, 80 

yELLOW fever, 449 
^APPERT counting chamber, 44 



INDEX OF AUTHORS. 



A BBOTT, HQ 
*■ Achalme, 113, 422 


Bloodgood, 358 


Blumer, 299, 436 


Achard, 304 
Adami, 85, ill 


Boeckman, 159 


Boeni, 196 


Addison, 299 


Bohland, 180, 195, 206 


Afanassiew, 113, 419 


Bojanus, 196 
Bordet, 87, 88 


Affleck, 402 


Agramonte, 450 


Bouchut, 313 


Aiello, 348 


Bradford, 261 


Albutt, 217 


Bramwell, 21 1, 398 
Brandenberg, 96, 417 


Aldridge, 395 


Altmann, 158 




Ames, 193 


Briefer A2Q 


Aoyoma, 307 


Brouardel, 316, 448 


Aporti, 120 


Brown, iqq. i$8. aii. a^C. A.16. aao. AA2 


Archinard, 450 


Bruce, iqa. 


Arloing, 437, 438 


Buard, 438 


Arnold, 164 


Buchner, 185, 196 


Arsamaskofif, 395 


Burmin, 96, 210, 247 


AcTiforrl iCt 




Askanazy, 99, 35^ 


l^urr AOC 


Atkinson, 436 


Burrows, 193, 404 


A 11 pV\p a 1 1 


/^ATSOT n8 182 206 211 211; 2aa 


"DADUEL, 412 


^ 2-l8 2o8 106 2A.1 788 30*7 108 


U Baginsky, 286, 424 


401, 402, 408, 410, 414, 416, 422, 
AT? A2A /I "26 ACI 


Balfour, 1 13, 444 

Ttarkpr TC8 


Caripf' it? 


Bastianelli, 359, 360 


Canard, 96 


Beck 


Canon, 199, 202, 308, 354> 429 


T^prker 00 A I C 


Cantani, 97, 304* 34^ 


BecOjiierel, 106, 354 


Canns 7C no 17 f iqi "j88 aoi 


Behier, 241 
Benario 62 


Carroll, 450 


Cnrtpr ill 11 A 


Benda, 259 


Cassel, 285, 286 


Bendix, 438 


Castellani, 317 


Bennett, 246 


Castellino, 139 


Bensaude, 304 


Celli, 359 


Benzacon, 448 


Chadbourne, 193 


Berend, 96 


Charcot, 24 


Besredka, 195, 315 


Charles, 394 


Bettman, 347 


Charon, 287 


Bierfreund, 121, 242, 386 


Charrin, 87 


Biernacki, 304 


Chantemesse, 332 


Bignami, 359, 360, 371, 380, 381 


Chenzinsky, 68 


Billings, 306, 313, 314, 414, 445 


Class, 1 13, 424 


Birk, 196 


Cohn, 232 


Bize, 314 


Cole, 317 


Bjorkman, 181 


Combe, 395 


Blake, 343 


Councilman, 359 


Blix, 72 


Courmont, 417, 437, 438, 449 



INDEX OF 



AUTHORS. 



Cox, 395 
Coyon, 422 
Craig, 113 
Crajkowski, 424 
Curschmann, 318 
Czerniewski, 428 
Czerny, 273, 274 

Da COSTA, 416 
Daland, 72 
Dale, 433 
Dane, 440, 442 
Dare, 36 
Dawson, 242 
De Amicis, 408 
Decastelle, 204 
Delafield, 69 
Delbert, 244 
Delestre, 292 
Delezene, 206 
Denige, 110 
Denys, 350 
De Rienzi, 196, 353 
de Saussure, 335 
Desevres, 97 
Determann, 71 
Diabella, 100 
Dinkelspiel, 88 
Dionisi, 379, 381 
Dock, 359 
D'Orlandi, 205 
Douglas, 388 
Drouin, 96, 97, 332 
Dubroisay, 313 
Dunn, 335 
Durham, 52, 87 
Duval, 346 

EBSTEIN, 261 
Egger, 133 
Ehrlich, 58, 59, 62, 63, 64, 68, 142, 145, 
148, 158, 171, 173, 176, 184, 187, 197, 
205, 242, 341, 357, 409,417 
Eichhorst, 137 
Eisenlohr, 262 
Engel, 77, 96, 147, 447 
Engle, 316 
Eubank, 242 

Ewing, 193, 314, 315, 413, 445 

PAJARDO, 402 

* Felsenthal, 314, 425 

File, 313 

Filetti, 359 

Fink, 306 

Finlay, 450 

Fischl, 281 

Fodor, 334 

Fraenkel, 261, 262 

Freudberg, 96 



Freund, 108 
Friedlander, 181 
Frolich, 408 
Fussell, 261 
Futcher, 69, 176, 361 

PABRITSCHEWSKY, 156, 185, 306, 
U 3H 

Garrod, 109, 347 
Gaylord, 385 
Georgiewsky, 416 
Gilbert, 313, 314 
Goldberger, 174 
Goldhorn, 69 
Goldscheider, 185, 194 
Golgi, 359 
Gollasch, 199 
Gowers, 25,' 34, 54 
Gradwohl, 424 
Graeber, 210 
Gram, 129 
Grassi, 359, 360 
Gratea, 287 

Grawitz, 134, 147, 159, 213, 247, 298, 
309, 316, 349, 351, 354, 392, 401, 
416, 417, 429, 446, 447 

Greene, 223, 319 

Greenough, 345 

Griesinger, 357 

Gruber, 87 

Guiteras, 335 

Gundobin, 178, 282 

Giinther, 86 

Gwyn, 318, 398, 436 

HAGEN, 274 
Hall, 242 
Halla, 159, 448 
Hamel, 148, 417 

Hammerschlag, 75, 99, 210, 280, 423 

Hand, 196 

Hankin, 158, 196 

Hanot, 352 

Hardy, 155, 164 

Hare, 414 

Harris, 1 70 

Hartley, 274 

Hartmann, 272 

Hartung, 388 

Hay, 316 

Hay craft, 77 

Hayek, 251 

Hayem, 41, 102, 128, 129, 131, 132, 

I 3 8 , ! 59, 2I 9> 228 » 2 4°» 28o > 28l » 

331, 350, 387, 400, 416 
Head, 192 
Hedin, 72 
Heidenrich, 421 
Heim, 415 
Henry, 335, 386 



472 



INDEX OF AUTHORS. 



Hewes, 65 
Hewetson, 359 
Hibbard, 180 
Hills, 220 
Hirscblaff, 429 
Hirt, 195 
Hofbauer, 175 
Hoffman, 388, 389 
Holmes, 68, 441 
Holt, 285 

Hoppe-Seyler, 108, 126, 309 
Howard, 361, 436 
Hubbard, 343 
Hubner, 356 
Hutchinson, 421 

TMMERMAN, 240, 348 
A Israel, 142 

JACOB, 185, 194 

J James, 84, 311,317, 392, 399, 41 2,492 

Jacques, 424 

Jeffries, 96 

Jehle, 354, 424 

Jellinek, 119 

Jenner, 63, 64 

Johnston, 322 

Jones, 433, 451 

Jopson, 261 

Joslin, 345 

Justus, 433 

TZAMINER, 175 

Kanthack, 155, 158, 164, 196 
Kelsch, 244, 381, 382 
Kerr, 435, 436 
Kisch, 405 
Kitasato, 306 
Klein, 354 
Kline, 431 
Kobert, 417 
Koblanck, 204 
Kochetkoff, 425 
Koeppe, 133 
Kohn, 412 
Kolisch, 176 
Kolle, 87 
Kolliker, I42 
Kormoczi, 262 
Kraepelin, 398 
Kraus, 77, 96, 98, 334, 392 
Krause, 318 
Krausman, 195 
Krauss, 428 
Kretz, 395 

Krokiewicz, 385, 388 

Kronig, 417 

Kuhlman, 405 

Kiibnau, 317, 354, 392, 428 

Kurloff, 274 



T AACHE, 134, 241, 400 
^ Lambert, 355 
Landois, 77, 99 
Laptschinski, 421 
Latham, 286 
Laveran, 359 
Lazarus, 58, 341 
Lazear, 69, 392, 450 
Le Breton, 398 
Lehmann, 96 

Lechtenstern, 311, 357, 406 

Lenoble, 219, 236 

Lepine, 96 

Lesieur, 417 

Letzericb, 348 

Levene, 355 

Levy, 347 

Lewaschew, 444 

Lichty, 99, 344 

Liebrich, 77 

Lindenthal, 145, 417 

Litten, 148 

Lloyd- Jones, 99, 209 

Loffler, 65 

Lothrop, 336, 341 

Lowenthal, 420 

Lowit, 186, 194, 244, 259, 344 

Lowy, 96, 185, 237, 334 

Luciani, 205 

Lussana, 356 

Luxemberg, 402 

Lyon, 192 

MacCALLUM, 367 
-L™- Mackenzie, 1 15 
Mackie, 426 
MacPhail, 403, 405 
Mannaberg, 359, 371 
Manson, 335, 337, 339, 341 
Maraghano, 139, 333, 385 
Marchiafava, 359, 371, 380 
Mastin, 355 
Mathias, 353 

McCrae, 232, 251, 387, 388 
Mertins, 433 

Metchnikoff, 87, 156, 359 
Meunier, 352, 408 
Meyer, 195 
Mickulicz, 121 
Miescher, 30 
Mitchell, 181 
Mongour, 438 
Montagard, 449 
Monti, 284, 288 

Morse, 284, 285, 286, 290, 313, 409 
Muir, 186, 349 

Miiller, 151, 255, 262, 263, 286, 388, 416 
Murray, 398 
Musser, 394 
Mya, 96 



INDEX OF AUTHORS. 



473 



TVTETTER, 308 
iy Neufeld, 318 
Neunian, 436 
Neumann, 142, 429 
Neusser, 176, 201, 406 
Nicholls, 151 
Nikiforoff, 62 
Nuttal, 88 

ABERMEIER, 418 
^ Oertel, 410, 446 
Ogata, 307 
Okladnych, 304 

Oliver, 25, 32, 41, 56, 106, 122, 130, 
133, 181 

Osier, 217, 232, 234, 271, 359, 376, 

387, 388 
Ostrovosky, 356 
Otto, 242 

UACCHIONI, 408 

r Page, 424 

Pallowski, 244 

Pappenheim, 142, 147 

Pee, 424, 435 

Peiper, 98, 99, 423 

Perry, 198 

Peter, 434 

Petrone, 101 

Petruschky, 428 

Pfeiffer, 86, 103, 354, 448 

Pick, 448 

Pieraccini, 412 

Plehn, 68 

Plimmer, 385 

Poggi, 121 

Pohl, 195 

Pollman, 285 

Ponfick, 138 

Porter, 113, 444 

Pothier, 450, 451 

Pratt, 336, 341 

Prince, 66 

Putnam, 398 

QUINCKE, 220 

RABINOWITCH, 438 
Ranvier, 355 
Reed, 448, 450 
Rees, 307 

Reinert, 134, 333, 403 
Rey, 332 
Reyne, 132 
Reyner, 356 
Richard, 359 
Richardson, 274, 318 
Richter, 185, 334 

Rieder, 159, 179, 180, 191, 192, 201, 
255, 3i3» 355, 397, 435 



Rigler, 334 
Rindfleisch, 142 
Ritchie, 406 
Rodier, 106, 354 
Roger, 87 
Rolleston, 286 
Rollet, 127 
Romberg, 439 
Rosin, 119 
Ross, 360 
Rost, 402 
Rotch, 281 
Roy, 75 
Rumpff, 96 
Russell, 385 

OAILER, 394 
^ Samrazes, 353 
Sanarelli, 113, 450 
Sarnow, 419 
Schafer, 134 
Schaffer, 127 
Schaumann, 356 
Schiff, 280 
Schlesinger, 313 
Schmaltz, 99 
Schmidt, 99, 304, 334 
Schneyer, 388 
Scholz, 318 
Schottmiiller, 317 
Schreiber, 195 
Schultz, 187 

Schultz-Schultzenstein, 96 
Schultze, 155, 355 
Schiitze, 88 
Schwinge, 131 
Sfameni, 131, 181 
Shaw, 261 

Sherrington, 41, 164, 185, 202, 305 
Silvestrini, 412 
Simon, IIO, 1 76 
Sippy, 234 

Sittmann, 308, 392, 411, 428 

Slaughter, 335 

Slawyk, 354 

Smith, 394 

Smyth, 404, 405 

Sobotka, 445 

Solley, 62 

Somers, 404 

Sommerfeld, 424 

Sorby, 81 

Sorensen, 131, 400 
Spencer, 402 

Stengel, 50, 135, 151, 183, 289, 350, 

417, 446 
Stephens, 383 
Stern, 318 

Sternberg, 359, 450, 451 
Stierlin, 134 



474 



INDEX OF AUTHORS. 



Stockman, 120 
Stokes, 151 
Straus, 304 
Strauss, 96, 334 
Streker, 358 
Stump, 436 
Symes, 428 

JALLQU1ST, 39, 417 
■"• Tassinari, 96 
Taylor, 202, 247, 248, 261 
Tchlenorff, 98 
Teichmann, 120 

Thayer, 162, 181, 21 1, 215, 286, 326, 

329, 359, 361, 368, 369, 379, 392 
Theodor, 287 
Thiemich, 318 
Thoma. 40, 42, 159 
Thomas, 98 
Toisson, 41 
Triboulet, 113, 422 
Trinkler, 108, 385 
Tschirkoff, 299 
Tschistowitch, 406 
Tumas, 159, 444 
Tfirk, 171, 245, 332, 397, 423 
Tuttle, 84, 317, 392, 399, 412, 429 
Tyson, 272 

TTHLENMUTH, 88 
^ Uskow, 173 

yAILLANT, 417 
* Vaillard, 244 
Van den Berg, 423, 425, 426 
Van Gieson, 355. 
Van Emden, 228, 239 
Vasquez, 272 
Vast. 417 
Viault, 133 
Vicarelli, 135 
Vincent, 355 
von Bockmann, 421 



von Fleischl, 25 

von Jaksch, 96, [98/108, no, 124, 290, 

334, 399, 406, 414, 419 
von Lerber, 193 

von Limbeck, 96, 133, 135, 159, 179, 
188, 195, 228, 237, 255, 332, 334, 
351, 353, 399, 406, 421, 448, 449 

von Noorden, 143, 147, 199, 306 

Vorbach, 346 

Vulpius, 273 

IITALDVOGEL, 220 
• * Warren, 273 
Warthin, 128 
Wassermann, 88 
Watson, 347 
Weber, 395, 448 
Wegefarth, 151 
Weil, 262, 449 
Weiss, 158, 174 
Welch, 83, 428 
Wentworth, 178 

White, 180, 289, 399, '41 1, 428 

Whitney, 178 

Widal, 87, 322, 448 

Widowitz, 425 

Wilkinson, 195, 198 

Williams, 397 

Williamson, 77, 309 

Wiltschour, 317 

Winiarski, 358 

Winternitz, 18 1, 194, 204 

Wolff, 133 

Wood, 356, 450 

Wright, 80, 348, 349, 394 

Wyss, 416 

Y^RSIN, 306 
1 Young, 299 

7ANDY, 195 

L< Zappert, 44, 199, 425 

Zuntz, 96 



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